What happened
On August 20, 1998, an R22 helicopter, registration PT-YLM, was performing a transport flight from Rio de Janeiro to a warehouse facility operated by Lua Nova Indústria e Comércio de Produtos Alimentícios in Duque de Caxias, RJ.
The authorized helipad at the location was closed due to ongoing construction, forcing the operator to use adjacent areas for landings and takeoffs. On the day of the accident, the pilot decided to land directly on the warehouse loading yard to avoid taxiing through an area cluttered with construction materials.
As the aircraft was approximately 1.5 meters above the ground during the final approach, the downwash from the main rotor caused a wooden plywood board, located under the eaves of a building, to be lifted into the path of the tail rotor. The resulting strike caused a loss of control, leading the aircraft to strike a building's metal structure before impacting the ground. The pilot was uninjured, but the aircraft sustained severe damage to the airframe, rotors, tail cone, and transmission.
The investigation
CENIPA's investigation established that the landing site was not an authorized landing area, as the company had not sought permission from the Regional Civil Aviation Service (SERAC) to operate outside the official helipad. The investigation found that while the pilot had been using the adjacent grassy area for landings for five days, the accumulation of materials on the day of the accident prompted the decision to land directly on the yard.
Investigators noted a lack of ground support personnel to coordinate the landing or warn the pilot of hazards. Furthermore, the company lacked a specialized flight operations manager or established safety procedures for managing landings at its facilities. The investigation also highlighted that the distance between the aircraft and the obstacles was insufficient to mitigate the risk of debris being displaced by rotor downwash.
Findings
- Deficient Judgment: The pilot chose to perform a landing in a high-risk area rather than utilizing the safer, previously established approach to the nearby grassy area.
- Deficient Supervision: The company lacked a dedicated department to control and supervise flight operations and had no formal safety guidelines for takeoff and landing procedures at its installations.
- Deficient Infrastructure: The company failed to establish a safe, alternative landing site following the closure of the official helipad.
- Deficient Support: There was no ground crew present to assist with the landing, monitor the area for hazards, or communicate potential risks to the pilot.
- Low Situational Awareness: A lack of organizational awareness regarding the hazards presented by the construction environment contributed to the sequence of events.