What happened
On June 10, 1999, at approximately 23:15, an AS-350BA helicopter, registration PT-YPF, crashed into a hill near the municipality of Tijuc and Santa Catarina, Brazil. The aircraft was performing a police mission involving the transport of an authority between Florianópolis, Joinville, and Navegantes.
After departing Joinville and making a technical stop in Navegantes to drop off a passenger, the crew continued toward Florianópolis. While the flight was planned under Visual Flight Rules (VFR) at night, witnesses reported the presence of fog in the area. The aircraft was last heard from at 23:06, reporting an altitude of 500 feet. Shortly after, the helicopter was seen flying in circles over Tijucas and entering a bank of fog, where it struck a tree and subsequently collided with the terrain. The impact destroyed the aircraft, and all three occupants sustained fatal injuries.
The investigation
CENIPA's investigation examined the mechanical, meteorological, and operational aspects of the flight. Technical analysis of the engine by Rolls Royce confirmed it was functioning perfectly at the time of impact. While investigators looked into potential hydraulic system failures or inadvertent activation of cockpit controls, no conclusive evidence of mechanical failure was found.
The investigation focused heavily on the pilot's qualifications and the operational environment of the Santa Catarina Military Police Air Group. It was established that the pilot lacked IFR (Instrument Flight Rules) certification, and the aircraft was not certified for IFR operations. Furthermore, the investigation highlighted significant organizational deficiencies within the flight group, including a lack of standardized training and a weak safety culture.
Findings
- Inadequate Flight Qualifications: The pilot lacked the necessary IFR rating and sufficient experience for night operations.
- Meteorological Misjudgment: The pilot attempted to continue a VFR night flight through fog, which led to the collision with terrain.
- Operational Non-compliance: The flight violated regulations (IMA 100-4) by conducting a night VFR flight between terminals without the required IFR certification or aircraft certification.
- Pilot Fatigue: The pilot had been on duty for over 15 hours without adequate rest, which likely reduced situational awareness.
- Organizational Deficiencies: The Air Group lacked a standardized training program, had poor supervision, and suffered from internal conflicts and a lack of flight safety culture.
- Inadequate Training: There was no formal program for the qualification or operational progression of crew members.