What happened
On June 13, 1993, a Robinson R22 helicopter departed from the private Anhembí helipad in São Paulo for a flight over the city. The aircraft was operated by an individual who, at the time of the accident, did not hold a valid license to pilot helicopters. During the flight, approximately five minutes after takeoff, the engine began operating irregularly with a loss of RPM.
The pilot attempted to execute an autorotation procedure but was unsuccessful. During the descent, the aircraft struck the roof of a residence on Rua Turiassu before impacting the ground violently. The collision resulted in one fatality and one person suffering severe injuries. The aircraft sustained damage beyond repair.
The investigation
CENIPA's investigation revealed that the pilot lacked the necessary technical training, theoretical knowledge, or practical experience to safely operate the helicopter. Although the pilot claimed 360 flight hours in the model, this experience was not officially recorded through a certified training program. Furthermore, the pilot's psychological profile showed a disregard for flight safety regulations and an excessive self-confidence.
The investigation also examined the aircraft's airworthiness. The PT-HVH was operating with a suspended airworthiness certificate due to irregular documentation. While a visual inspection of the engine by a third party was inconclusive, a subsequent disassembly by the investigation team revealed that the engine was in poor condition, specifically noting that two spark plugs were loose and could be removed by hand.
Additionally, the investigation noted that the pilot failed to provide an emergency briefing to the passenger. There were also unconfirmed reports that the passenger attempted to jump from the aircraft moments before impact, an event that may have further distracted the pilot during the critical autorotation attempt.
Findings
- Lack of Qualification: The pilot was operating the aircraft without a valid helicopter pilot license or approved training.
- Improper Emergency Technique: The pilot's incorrect application of flight controls during the engine malfunction prevented a successful autorotation.
- Maintenance and Equipment Issues: Two spark plugs were found improperly installed (insufficient torque) in the engine.
- Operational Negligence: The pilot failed to instruct the passenger on emergency procedures, contributing to passenger panic.
- Regulatory Non-compliance: The aircraft was operating with irregular documentation and a suspended airworthiness certificate.
- Lack of Oversight: The helipad operator failed to verify the pilot's credentials prior to departure.