What happened
On May 25, 2018, at approximately 19:30 UTC, a Cessna 208B (registration PR-DOA) and a Bell 429 (registration PP-NEO) experienced a serious loss of separation near Santa Genoveva Airport (SBGO) in Goiânia, Brazil. The Cessna 208B, operated by the Federal Highway Police, departed on the LODUV 1B departure profile. Simultaneously, the PP-NEO departed from a taxiway, authorized to fly directly to Anápolis (SWNS) while maintaining 500 ft AGL.
Following takeoff, the pilot of the PP-NEO climbed to 3,800 ft and altered the departure heading without authorization or coordination with air traffic services. This deviation led to two separate close encounters. The first crossing occurred with a lateral separation of only 0.3 NM and a vertical separation of 100 ft. Shortly after, a second crossing occurred at the same altitude with a lateral separation of 0.4 NM. Despite the pilot of the PP-NEO reporting they were visually in contact with the Cessna 208B, the lack of separation persisted. No injuries were reported, and there was no damage to either aircraft.
The investigation
CENIPA's investigation focused on the actions of the flight crews and the effectiveness of air traffic control (ATC) coordination. Investigators found that the pilot in command of the PP-NEO was not properly qualified for the aircraft, as they lacked the required multi-engine turbine helicopter rating.
Regarding air traffic services, the investigation examined the roles of Goiânia Ground Control (GNDC-GO), the Goiânia Tower (TWR-SA), and Anápolis Approach (APP-AN). The investigation noted that the ground controller authorized the helicopter's departure without emphasizing the altitude restriction and that the separation of the two aircraft on different frequencies reduced the controllers' situational awareness. Furthermore, the investigation identified that the tower controller attempted to warn the Cessna 208B of the approaching helicopter, but the message was not received because the crew had already switched frequencies to Anápolis Approach.
Findings
- The pilot in command of the PP-NEO was not qualified to operate the aircraft, lacking the necessary multi-engine turbine rating.
- The pilot of the PP-NEO demonstrated non-compliance with regulations by deviating from the authorized altitude and flight path without coordination.
- Air traffic controllers failed to use available tools effectively to prevent the conflict, and there was an inadequate exchange of information between different ATC positions.
- The ground controller's authorization of the helicopter's departure, while not specifying the altitude, contributed to the loss of separation.
- Inadequate management supervision by the helicopter operator regarding crew qualification requirements was a contributing factor.
Safety action
CENIPA recommended that the Department of Air Space Control (DECEA) share the lessons learned from this investigation with NAV Brasil Serviços de Navegação Aérea. The goal is to increase the situational awareness of air traffic controllers regarding the importance of understanding operational models and correctly applying the tools available for air traffic services.