ASN Wikibase Occurrence # 188411
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| Date: | Sunday 26 June 2016 |
| Time: | c. 08:15 LT |
| Type: |  Bell 407 |
| Owner/operator: | Ale Costa Negócios e Participacões |
| Registration: | PR-CBB |
| MSN: | 53926 |
| Year of manufacture: | 2009 |
| Fatalities: | Fatalities: 5 / Occupants: 5 |
| Aircraft damage: | Destroyed |
| Category: | Accident |
| Location: | near Jundiaí, SP -
 Brazil
|
| Phase: | En route |
| Nature: | Executive |
| Departure airport: | São Paulo-Congonhas |
| Americana | |
| Investigating agency: | CENIPA |
| Confidence Rating: |  Accident investigation report completed and information captured |
The Bell 407 crashed and caught fire near Jundiaí, SP. All five occupants died.
Contributing factors.
- Adverse meteorological conditions – undetermined.
Degraded weather conditions may have influenced the decision of the pilot-in-command regarding deviations and variations in altitude verified by the radar revision, or even have led her to experience visual illusions that affected her ability to accurately perceive the environment, leading to the occurrence ending.
- Disorientation – undetermined.
The degradation of the meteorological conditions, the impact attitude of the aircraft and the impact energy itself signaled the possibility of a spatial disorientation by visual and/or vestibular illusion as the most probable hypothesis to explain the dynamics of the accident.
- Illusions – undetermined.
In the present case, the visual illusion of the false horizon may have occurred, related to the bad perception of the horizon, common in flights with degradations in the meteorology with lack of visual references; and/or the somatographic illusion that affects the spatial orientation, as much by the bad perception of the visual system, as of the vestibular system.
- Piloting judgment – a contributor.
There was an inadequate evaluation of the parameters related to the operation of the aircraft by maintaining the flight altitude close to the altitude of the elevations, considering the unfavorable weather conditions.
- Perception – undetermined.
The degradation of the meteorological conditions may have resulted in difficulties in the perception of external visual references. Associated with the difficulties of spatial reasoning presented by the pilot, this condition may have compromised her ability to properly discriminate position in space and the movement of her aircraft with respect to the Earth's horizon, favoring collision against the ground.
- Decision-making process – a contributor.
The decision to continue the visual flight in an unfavorable weather scenario denoted an imprecise assessment of the criticality and risks involved in that operational context, which presented elements favorable to spatial disorientation.
- Organizational processes – a contributor.
There were flaws related to the health inspection process to the pilot to obtain the CMA. These failures made it possible to obtain a medical certificate for the revalidation of the PCH license, without proper approval at the initial inspection, as well as obtaining approval at the initial inspection for the PLH license, although at the time of the evaluation, the pilot did not attend the criteria adopted by the regulatory body.
- Support systems – undetermined.
The gaps observed in the legislation that governs health inspections (RBAC 67), especially regarding the aspects to be evaluated in relation to each cognitive ability, may have favored discrepancies in the evaluative process and made it impossible to detect difficulties related to the pilot’s spatial reasoning.
The absence of clear and precise criteria for the pilot function evaluation indicated flaws in this reference material, which was used for psychological assessment at initial health inspections, requiring the evaluator's discretion to determine his or her evaluation.
Accident investigation:
 |
|
Sources:
http://g1.globo.com/sao-paulo/noticia/2016/06/bombeiros-localizam-helicoptero-que-caiu-na-regiao-de-cajamar.html
http://www.cavok.com.br/blog/acidente-com-helicoptero-bell-407-em-sao-paulo/
http://www.rotorspot.nl/product/b407.php
http://sistema.cenipa.aer.mil.br/cenipa/paginas/relatorios/rf/en/PR-CBB_26_06_2016-AC..pdf
Media:
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 27-Jun-2016 19:51 | junior sjc | Added |
| 27-Jun-2016 19:52 | harro | Updated [Narrative] |
| 28-Jun-2016 06:31 | Black Typhoon | Updated [Operator, Nature, Departure airport, Destination airport] |
| 28-Jun-2016 11:51 | Iceman 29 | Updated [Embed code] |
| 28-Jun-2016 17:19 | Black Typhoon | Updated [Time, Destination airport] |
| 26-May-2020 14:52 | KagurazakaHanayo | Updated [Source, Narrative] |
| 26-May-2020 14:53 | harro | Updated [Narrative, Accident report, ] |
Corrections or additions? ... Edit this accident description
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