ASN Wikibase Occurrence # 143915
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| Date: | Wednesday 22 February 2012 |
| Time: | 10:30 LT |
| Type: |  Eurocopter AS 350BA Ecureuil |
| Owner/operator: | Corpo de Bombeiros Militar do Estado do Pará |
| Registration: | PT-YAK |
| MSN: | 2756 |
| Year of manufacture: | 1993 |
| Fatalities: | Fatalities: 0 / Occupants: 4 |
| Aircraft damage: | Substantial |
| Category: | Accident |
| Location: | nr Marituba, PA -
 Brazil
|
| Phase: | Landing |
| Nature: | Survey |
| Departure airport: | Belém/Val de Cans–Júlio Cezar Ribeiro International Airport |
| Belém/Val de Cans–Júlio Cezar Ribeiro International Airport | |
| Investigating agency: | CENIPA |
| Confidence Rating: |  Accident investigation report completed and information captured |
The helicopter took off from the patio of the GRAESP (Public Security Air Unit) located in SBBE, with two crew members and two passengers on board, with the intent of flying over the BR-316 highway, as part of the 2012 Carnival Operation.
Approximately 10 minutes into the flight, with the aircraft leveled off at an altitude of 600ft, a strong vibration was felt, and the crew identified a surge in the main rotor rotation.
An emergency landing was made in an area of barren land close to the BR-316 highway, after the crew performed procedures aimed at reducing the rotation of the main rotor.
While the aircraft was landing, still with high rotation of the main rotor, vibrations occurred that were characteristic of ground resonance and that in a few seconds caused substantial damage to the aircraft structure.
Contributing factors.
- Stress – undetermined.
The mechanic was experiencing stressing work conditions, which would have diminishing his ability to pay attention and concentrate while providing aircraft with maintenance services, which can be done with he did not notice the contamination conditions of the fuel and the FCU.
- Organizational culture – a contributor.
The culture of the organization overvalued its operational mission in detriment of flight safety. In consequence, important procedures, such as keeping a maintenance inspector and requesting fuel tests, were skipped.
- Flight indiscipline – undetermined.
The validity of the first officer’s technical qualification certificate had expired, but he was composing the crew according to the aircraft logbook records, contrary to the prescriptions of the legislation in force. The fact that the aircraft could be flown by just one pilot does not exempt the other pilot, as a crew member had a valid qualification.
- Aircraft maintenance – a contributor.
The services of maintenance and balance of the main rotor blades were not provided in the way prescribed by the manufacturer, altering the frequency of rotation of the blades and aggravating the ground resonance event. There were also components installed in the head of the rotor that could not have their traceability verified and, therefore, one understands that the aircraft could not be considered airworthy.
- Management planning – undetermined.
The fact that there was just one mechanic qualified to control and maintain the airworthiness of the fleet aircraft denotes deficiency in the allocation of human resources for the execution of operational and maintenance activities both on the part of the operator and of the maintenance provider and may have resulted in failure to identify abnormal conditions of the aircraft.
- Organizational processes – a contributor.
The lack of a process for monitoring and controlling the activities carried out in the company allowed existing dysfunctions (such as shortage of maintenance personnel, stressing work conditions, lack of supervision of the services, and pilot operating with an expired qualification) not to be corrected.
- Managerial oversight – undetermined.
Neither the maintenance providing company nor the operator could provide information on the traceability of the components installed in the aircraft, showing that they were not aware of the real airworthiness condition of the aircraft. Besides, the operator allowed that pilots with an expired qualification could compose a flight crew, something that goes against the legislation.
Accident investigation:
 |
|
Sources:
http://prevencao.potter.net.br/file/45571/EN/PTYAK
Media:
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 24-Feb-2012 02:47 | harro | Added |
| 24-Feb-2012 04:16 | RobertMB | Updated [Time, Aircraft type, Cn, Operator, Location, Destination airport, Source, Embed code, Narrative] |
| 26-Dec-2016 19:39 | harro | Updated [Aircraft type, Cn, Location, Nature, Departure airport, Destination airport, Source, Narrative] |
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