What happened
On July 27, 2001, at approximately 18:35 local time, an Agusta A 109E helicopter, registration PP-MPA, operated by Flylight Comercial Ltda, struck the surface of the sea near Maresias, São Paulo. The flight originated from Campo de Marte, initially proceeding to a private helipad in São Paulo before continuing to the coastal destination.
During the final approach to the Maresias helipad, the aircraft encountered moderate and constant rain. The helicopter struck the water approximately 1.8 nautical miles from the destination. While all four occupants managed to evacuate the aircraft before it sank, the impact and subsequent immersion were violent. Two individuals, the pilot and one passenger, managed to swim to the shore, but the commander and one passenger tragically drowned.
The investigation
CENIPA investigators examined the wreckage in Osasco, São and analyzed various components, including instruments and engine parts. The investigation established that the engines and main rotor blades showed clear evidence of impacting the water while operating at high power. Mechanical analysis of the transmission shafts revealed they had broken due to torsion, further indicating the engines were producing significant power at the moment of impact.
Investigators also examined flight instruments, including the artificial horizon and radio altimeter. Tests suggested that certain cockpit lights may have been extinguished at the time of impact. The investigation noted that the crew had utilized a non-certified GPS-based descent procedure and had deliberately deactivated the ground proximity warning alarm. Furthermore, the investigation found that the crew had operated without a flight plan or communication with air traffic control for the second leg of the flight.
Findings
- Adverse weather conditions involving heavy rain and low visibility significantly hindered the pilot's situational awareness regarding the aircraft's altitude relative to the dark sea surface.
- Improper flight planning and judgment, as the crew proceeded with a visual flight rules (VFR) approach despite encountering instrument meteorological conditions (IMC).
- Operational indiscipline, including flying without a flight plan, failing to contact air traffic control, and using non-homologated navigation equipment and procedures.
- Inadequate crew coordination and monitoring, specifically regarding the management of power and flight path during the final stages of the approach.
- Lack of safety equipment, as the aircraft was not carrying life jackets for the occupants.
- Human factors, including potential physical fatigue from a long duty day and a psychological drive to complete the mission despite deteriorating weather.