What happened
On July 7, 2015, at approximately 18:40 UTC, a Bell 206L-4 helicopter, registration PR-HMA, was conducting an environmental inspection mission for IBAMA in the Reserva de Gurupi, Bom Jardim, Brazil. The flight originated from Pindaré Mirim, MA, carrying three crew members and three passengers.
While attempting to land in a restricted area, the aircraft's main rotor blades struck tree branches. Following the impact, the pilot executed a go-around and proceeded to the operations base, located approximately 75 NM away. The aircraft sustained light damage, and all six occupants escaped without injury.
The investigation
CENIPA's investigation focused on the operational environment and crew dynamics during the landing attempt. The investigation established that the Special Equipment Operator (OEE) was operating in an unfamiliar configuration. Unlike the AS350 model the operator typically flew, the tail rotor on this aircraft was positioned on the left, requiring the OEE to monitor the aircraft from that side.
Furthermore, the presence of passengers in the cabin restricted the OEE's ability to move internally to monitor the opposite side of the aircraft. The investigation also noted that the crew was unfamiliar with one another, as this was their first flight together. During the first landing attempt, a verbal conflict arose when the pilot spoke sharply to the OEE, creating a communication barrier. During the second attempt, the OEE remained silent, leaving the pilot to manage both the forward and lateral positioning of the aircraft without effective external guidance.
Findings
- Communication breakdown: A breakdown in Crew Resource Management (CRM) and interpersonal conflict between the pilot and the OEE led to a lack of situational awareness.
- Inadequate training: There was a lack of standardized training for landing in restricted areas and a lack of recent proficiency training for the pilot in such maneuvers.
- Ergonomic limitations: The cabin configuration, crowded by passengers, prevented the OEE from effectively monitoring the entire perimeter of the aircraft.
- Organizational factors: The lack of standardized procedures and standardized phraseology among various personnel seconded to IBAMA contributed to potential misunderstandings.
- Lack of standardization: There were no established requirements for the experience levels or specific training of external crew members provided to the operator.