What happened
On May 15, 1998, at approximately 01:10Z, a Bell 206B helicopter, registration PT-HHJ, collided with a hill in the Bairro Cururuquera region of Santana do Parnaíba, São Paulo. The aircraft had departed from Sorocaba earlier that night, intending to fly to a helipad in São Paulo. The flight was conducted under the guise of a visual flight (VFR) flight plan, though the aircraft was actually performing an unauthorized air taxi operation.
During the flight, the aircraft entered a mountainous area under dark night conditions with a low cloud ceiling of approximately 200 feet. The pilot, attempting to maintain visual contact with the ground, likely sought to follow a nearby highway. However, the aircraft struck a hillside at an altitude of 3,100 feet while traveling at cruise speed. The impact caused an immediate explosion and fire, resulting in the three fatalities of the pilot and two passengers.
The investigation
CENIPA's investigation established that the pilot was operating as a private pilot without the necessary Instrument Flight Rules (IFR) rating or a Commercial Pilot License (PCH) required for air taxi services. The investigation revealed that the pilot had a history of flight rule violations and had previously been involved in a fatal accident in 1993 while unqualified.
Engine analysis by the Allison Engine Company indicated that the engine was producing high power and the aircraft was at cruise speed at the moment of impact. Investigators also found that the aircraft's maintenance logs were outdated and that the pilot had intentionally flown under cloud cover in violation of established separation minimums. Furthermore, the investigation noted a psychological profile for the pilot that indicated a high propensity for risk-taking.
Findings
- Improper Flight Qualifications: The pilot was a private pilot performing unauthorized air taxi operations without the required commercial certification or IFR rating.
- Adverse Weather: Low cloud ceilings and dark night conditions significantly restricted visibility and made visual navigation in mountainous terrain extremely dangerous.
- Poor Decision Making: The pilot attempted to descend below the cloud layer to regain visual contact with the ground, which led to the collision with the terrain.
- Lack of Oversight: The aircraft owner permitted the use of a private category aircraft for commercial air taxi purposes.
- Risk-Taking Behavior: The pilot's psychological profile demonstrated a pattern of accepting excessive risks and disregarding aeronautical regulations.
Safety action
- The investigation recommended that aviation schools and air taxi companies disseminate the findings of this accident to improve safety awareness.
- A recommendation was made to the Institute of Psychology of the Air Force to establish desirable psychological profiles for aeronauts to prevent pilots with dangerous risk-taking tendencies from maintaining flight credentials.
- The Civil Aviation Department was urged to evaluate modifications to health and physical capacity certifications to allow psychologists to veto aeronauts whose psychological profiles compromise flight safety.