What happened
On March 13, 2021, an Agusta A109S, registration PP-UGS, was performing a private flight from the Bira Guimarães Private Helipad (SIIX) to Campo de Marte Aerodrome (SBMT) in São Paulo. The flight included an intermediate landing at an unregistered, rural location in Igaratá, SP, intended to board an elderly passenger with mobility restrictions.
During the final approach to this unregistered landing site, the aircraft's tail rotor blades struck a lamp post approximately 5 meters in height. The impact caused light damage to the tail rotor and damage to the lamp post. The pilot was uninjured.
The investigation
CENIPA's investigation established that the landing site was a flat, grassy area surrounded by trees, approximately 400 meters from the initial takeoff point. The site lacked any formal markings, communication services, or ground observers to assist with the approach. The pilot was performing the landing at this specific location for the first time.
Investigators found that while the pilot was qualified and experienced, the landing area was constrained. The obstacle-free area was approximately 33 meters long by 14 meters wide, leaving a margin of only about 1.5 meters between the tips of the main rotor blades and the nearby obstacles. The investigation noted that the aircraft's owner was the passenger being boarded, and the pilot's desire to facilitate boarding for the passenger with limited mobility influenced the operational decisions.
Findings
- Inadequate risk management: The pilot failed to perform proper risk management or prior planning for landing in a restricted, unregistered area with known obstacles.
- Poor decision-making: The pilot's judgment was compromised by the motivation to accommodate the passenger's physical limitations, leading to an inadequate assessment of the operational environment.
- Lack of site support: The landing site lacked essential safety infrastructure, such as ground markings or personnel to direct the aircraft.
- Flight planning deficiencies: The selection of a landing site with significant obstacles without a structured approach plan contributed to the collision.