What happened
On November 9, 1997, an AS 350BA Esquilo helicopter, registration PP-EVC, operated by the Coordenadoria Geral de Operally Aéreas (CGOA), was performing a vertical takeoff from the Lagoa helipad in Rio de Janeiro. The aircraft was intended for a coastal patrol mission, carrying a crew consisting of a pilot, an assistant, a detective, and a lifeguard, along with one unauthorized passenger.
During the takeoff maneuver, the aircraft experienced a sudden loss of control, characterized by a left yaw and backward movement. The helicopter struck the ground in a nose-high attitude. The impact caused the main rotor to strike the tail boom, resulting in the failure of the tail rotor drive shaft and the detachment of the vertical stabilizer. The aircraft subsequently spun approximately 360 degrees before the main rotor struck the ground, causing extensive damage to the airframe, transmission, and cockpit.
The investigation
CENIPA's investigation revealed a profound lack of oversight and a breakdown in safety culture within the CGOA. The investigation established that the individual occupying the left seat, acting as the pilot in command during the takeoff, was a departmental assistant who possessed no pilot license and had allegedly used a fraudulent license to gain flight privileges. The actual pilot, positioned in the right seat, was not qualified to act as an instructor and had improperly delegated the takeoff to the unqualified assistant.
Investigators found that the aircraft was configured for dual controls, but the assistant's improper use of the pedals—applying full left pedal and pulling the cyclic toward his body—rendered the pilot's interventions ineffective. Furthermore, the investigation uncovered evidence of an attempt to obstruct the inquiry, including the intentional alteration of wreckage and the removal of evidence to hide the fact that the aircraft was being operated under unauthorized dual-command conditions. The investigation also noted that the crew was using improvised "monkey tail" restraints instead of standard seatbelts, and the mission itself lacked proper flight planning or safety briefings.
Findings
- Improper Flight Delegation: The pilot allowed an unqualified individual to perform the takeoff maneuver.
- Unqualified Personnel: The individual operating the controls had no valid pilot certification and had presented a false license.
- Loss of Control: The assistant's improper and panicked control inputs caused the aircraft to become uncontrollable.
- Organizational Failures: The CGOA lacked formal training, standardized operating procedures, and a functional safety culture, characterized by an environment of informality and non-compliance with aviation regulations.
- Safety Violations: The mission included an unauthorized passenger and lacked essential safety checks, such as verifying survival kits and passenger seatbelt security.