What happened
On January 1, 2000, at approximately 12:15 PM, an AS-350 B2 operated by Helimed Aero Táxi LTDA was performing short-duration passenger transfers between the official and private residences of the Governor of the Federal District in Brasília. During the event, a last-minute request was made to transport the Governor's sister and a military police officer to the private residence to retrieve a religious item.
Following a five-minute flight, the helicopter landed at an uncertified helipad. During the landing phase, the pilot's attention was momentarily diverted by an individual approaching the aircraft from the right side. As the aircraft came to a halt, the passenger exited through the left door and moved quickly toward the rear of the aircraft. While attempting to pass beneath the tail boom, the passenger struck the moving tail rotor, resulting in fatal injuries. The aircraft sustained minor damage to the tail rotor and transmission system.
The investigation
CENIPA's investigation focused on the operational environment and the pilot's decision-making process. Investigators found that the flight was unplanned and driven by the urgency of the passengers to return to a religious ceremony. The investigation noted that the pilot failed to conduct a mandatory safety briefing (brifem) for the passengers before takeoff. This omission was attributed to the pilot's erroneous assumption that the accompanying military officer would act as a safety agent and guide the passenger.
Furthermore, the investigation examined the suitability of the safety instruction cards on board. While present, these cards were found to be poorly positioned, inadequately sized, and lacked sufficient clarity for lay passengers. The investigation also noted that the landing site was not a certified aerodrome, and the operator had not established specific safety procedures for operating at such uncertified locations.
Findings
- The pilot's attention was diverted by an external stimulus (a person approaching the aircraft) during the landing phase.
- The pilot failed to provide the required verbal safety briefing to the passengers.
- High levels of anxiety and pressure to complete the unplanned mission contributed to a breakdown in standard safety procedures.
- The passenger's rapid movement toward the rear of the aircraft, combined with a lack of clear safety instructions, led to the fatal collision.
- The safety instruction cards were not ergonomically effective or easy to understand.
- The operation involved uncertified landing sites, and the operator lacked specific protocols for such operations.