What happened
On May 21, 1999, an HB 350 helicopter, registration PT-HLW, operated by Joly Green Táxi Aéreo, was conducting a flight to transport alumni to the 50th-annagary celebrations of the Air Cadet Preparatory School (EPCAR) in Barbacena, Minas Gerais. After several stops for passenger boarding and refueling, the flight arrived at its destination later than planned.
Due to the delay, the pilot decided to bypass the local airport and fly directly over the EPCAR campus to perform low-altitude flyovers. During these maneuvers, the aircraft performed a pass at an altitude of less than 100 feet. Following a tight left turn, the pilot executed an aggressive maneuver, pitching the nose down sharply. The pilot reportedly shouted that the aircraft would strike the trees. The main rotor struck trees, causing the tail rotor to detach and the aircraft to enter an uncontrolled descent. A post-impact fire completely destroyed the helicopter. The crash resulted in three fatalities (the pilot and two passengers), while the co-pilot and two other passengers sustained serious and minor injuries.
The investigation
CENIPA's investigation focused on the pilot's qualifications, the aircraft's performance, and the operational decisions made during the flight. Investigators found that while the co-pilot was qualified to fly the HB 350, the pilot lacked the specific technical qualification for this model. Furthermore, the aircraft was operating at a high weight of approximately 1,850 kg, near its maximum limit, at an altitude of 3,657 feet, which significantly reduced performance margins.
Mechanical inspections of the engine, transmission, and rotor components conducted at the site and at HELIBRÁS revealed no technical anomalies or maintenance failures. The investigation also noted that the flight violated regulations regarding minimum altitudes over populated areas and that the pilot'1s decision-making was influenced by a desire to demonstrate skill to former classmates.
Findings
- Pilot error and poor judgment: The pilot executed an excessively aggressive nose-down attitude during a turn, leading to an unrecoverable situation.
- Lack of qualification: The pilot was operating an aircraft model for which he was not technically rated.
- Organizational deficiencies: There was a lack of effective supervision within the operator, allowing an unqualified pilot to fly the aircraft, and a lack of Crew Resource Management (CRM), as the co-pilot acted as a passive passenger rather than monitoring the flight.
- Operational risks: The combination of high aircraft weight, high density altitude, and low-altitude maneuvers left no margin for error.
- Flight indiscipline: The pilot performed maneuvers below the minimum legal altitude for populated areas and operated without the required type rating.