What happened
On February 1, 2019, an MI-171A1 helicopter, registration PR-BR and operated by Costa do Sol Táxi Aéreo S.A., was involved in a ground collision at the Carauari Aerodrome (SWCA) in Amazonas. The flight had originally departed from Carauari for Base Fortaleza but was forced to return to its origin due to unfavorable weather conditions, specifically the appearance of dense fog known locally as "Aru."
Upon returning, the crew taxied the aircraft toward the parking apron. While positioning the helicopter to shut down the engines, the tail rotor struck the metal mesh of the fence surrounding the parking area. The impact caused light damage to the aircraft, specifically to the tips of the tail rotor blades and a small dent on the tail cone. The fence also sustained damage. All three crew members—the pilot, co-pilot, and flight mechanic—were uninjured.
The investigation
CENIPA investigators examined the cockpit procedures, crew coordination, and the physical infrastructure of the aerodrome. The investigation reviewed the flight history, which showed the pilots were highly experienced, with the pilot having over 6,600 total flight hours. The investigation also looked into the meteorological conditions and the operational environment of the Carauari Aerodrome, noting the lack of formal aeronautical meteorological services at the site.
Findings
- The pilot's improper judgment during taxiing led to the aircraft being positioned too close to the perimeter wall, with the wheels moving outside the designated apron boundaries.
- The pilot attempted to maneuver the aircraft within a restricted space to leave the apron clear for other aircraft, which resulted in an insufficient clearance for the tail rotor sweep.
- A lack of effective Crew Resource Management (CRM) was noted; the absence of a proper briefing regarding post-landing taxi procedures meant that the co-pilot and flight mechanic were not actively monitoring the external environment.
- The crew's situational awareness was diminished due to a lack of coordination and a failure to communicate specific tasks during the taxi phase.
- The physical limitations of the aerodrome, including limited parking capacity and the need to accommodate multiple rotary-wing operations, pressured the pilot's decision-making process.
Safety action
CENIPA issued several recommendations to the National Civil Aviation Agency (ANAC) and the local municipality. Specifically, it recommended that ANAC work with the operator to enhance CRM training regarding interpersonal interactions and safety during taxi and parking procedures. Additionally, recommendations were made to the Municipality of Carauari to improve the aerodrome's safety management system, including the implementation of an Airport Emergency Plan (PLEM) and a Firefighting Plan.