What happened
On September 18, 1999, at approximately 09:55 local time, a Bell 206 B helicopter, registration PT-HIZ, crashed into a hill near Santos Dumont, Minas Gerais. The aircraft, operated by Prática Escola de Pilotagem e Táxi Aéreo, was performing a flight from Jacarepaguá, Rio de Janeiro, to Belo Horizonte, Minas Gerais, to transport clients.
After departing Jacarepaguá, the flight was delayed by two hours due to deteriorating weather conditions. The pilot attempted to navigate through mountainous terrain under visual flight rules (VFR), despite facing heavy fog and low ceilings. Witnesses observed the helicopter flying in a zigzag pattern and entering and exiting cloud layers. While attempting to find visual breaks in the clouds, the aircraft struck a hill and exploded upon impact. The pilot was killed in the crash, and the aircraft was destroyed.
The investigation
CENIPA's investigation focused on the pilot's qualifications, the aircraft's capabilities, and the operational environment. Investigators established that the pilot, while holding a valid commercial license, was not rated for Instrument Flight Rules (IFR) flight. Furthermore, the PT-HIZ was not certified for IFR operations.
The investigation examined the pilot's experience, noting that although he had approximately 30 hours in this specific model, his experience was primarily limited to local instructional flights. The company had not provided the necessary route training required for this mission. Investigators also looked into the pilot's psychological and physiological state, noting high levels of anxiety due to the weather delays and the significance of this being his first scheduled route flight.
Findings
- Inadequate Pilot Experience: The pilot lacked the necessary experience for route operations and had not received specific training from the company for such missions.
- Instrument Limitations: The pilot was not rated for IFR, and the aircraft was not equipped or certified for instrument flight, yet the weather conditions necessitated IFR procedures.
- Adverse Weather: Low visibility, fog, and cloud layers obscuring mountain tops forced the pilot to fly dangerously close to the terrain to maintain visual contact.
- Operational Deficiencies: The company failed to provide adequate supervision for new pilots and did not implement a standardized training program for route flying.
- Poor Decision Making: The pilot attempted to bypass weather restrictions by filing a flight plan to a different destination (Três Rios) to maintain VFR status, ultimately leading to spatial disorientation in the mountains.
Safety action
Following the investigation, CENIPA issued several safety recommendations:
- The operator was required to establish minimum training requirements for newly hired pilots, specifically covering route and instructional flight stages.
- The company was directed to implement standardized procedures for supervising flight activities.
- Regulatory authorities (SERAC) were tasked with emphasizing the importance of pilot training programs during technical inspections and conducting special safety audits of the operator's training and safety culture.