ASN Wikibase Occurrence # 346680
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| Date: | Thursday 11 October 2018 |
| Time: | 21:00 UTC |
| Type: |  Agusta A109E |
| Owner/operator: | Band Participações e Gestão Ltda. |
| Registration: | PR-PMT |
| MSN: | 11101 |
| Year of manufacture: | 2000 |
| Fatalities: | Fatalities: 0 / Occupants: 7 |
| Aircraft damage: | Substantial |
| Category: | Accident |
| Location: | Iporanga-Guarujá Helipadm SP -
 Brazil
|
| Phase: | Approach |
| Nature: | Private |
| Departure airport: | Parque Paulista Helipad, São Paulo, SP (SDPT) |
| Iporanga-Guarujá Helipadm SP (SJNN) | |
| Investigating agency: | CENIPA |
| Confidence Rating: |  Accident investigation report completed and information captured |
At about 20:30 UTC, the aircraft took off from SDPT (Parque Paulista Helipad, São Paulo, SP), destined to SJNN (Iporanga-Guarujá Helipad, Guarujá, SP) on a private flight for passenger transport, with two crew and five passengers on board. At the final phase of the approach maneuver to land on the helipad, the helicopter lost height in an abnormal way, and crashed into the ground.
The aircraft sustained substantial damage. Neither the crew nor the passengers were injured
Contributing factors:
Attitude – a contributor.
Despite showing discomfort with the weather conditions and with the fact that the aircraft was above the weight and balance limits, the crew displayed non-compliance with the helicopter operational limits, by taking off and trying to land in a location that featured moderate turbulence and restrictions of ceiling and visibility.
Training – undetermined.
The corrective action of increasing the engine power by means of the collective to reverse the sinking situation on the final for landing revealed that the PIC did not have the necessary knowledge and training to correct and prevent a possible VRS.
Adverse meteorological conditions – undetermined.
One cannot rule out the possibility that the moderate turbulence reported by the pilot, as well as the ceiling and visibility conditions on account of the rain and lighting conditions in SJNN, contributed to compromise the ideal approach profile for landing at the destination.
Emotional state – a contributor.
According to PIC’s accounts, there was fear of losing their job if the flight was not accomplished. Thus, although the crew concluded that the weather conditions were unfavorable for the operation, the flight was conducted in a close relationship between the emotional state of the crew and the actions that contributed to the occurrence in question.
Handling of aircraft flight controls – undetermined.
On the final approach, the PIC possibly reduced the helicopter speed to a value below 30 kt., and performed a powered wide-angle approach with zero wind in a region of moderate turbulence. The use of this approach profile possibly contributed to the helicopter experiencing the VRS aerodynamic phenomenon.
Piloting judgment – a contributor.
Inappropriate evaluation on the part of the pilot of certain parameters related to the operation of the aircraft, such as flying with the aircraft above the weight limits for landing and outside the center of gravity, in a place subject to orographic turbulence and with degraded meteorology, contributed to the accident.
Motivation – a contributor.
According to the PIC report, flights with degraded meteorology took place frequently. Motivated by the fear of losing his job, even though feeling uncomfortable, the PIC decided to fly. In addition, the aircraft had been sent for maintenance and, during the process, the owner stressed that the flight had to take place, strongly influencing the pilots to release the aircraft within the period agreed with the shared-fleet managing company. As reported by the pilots, they felt pressure in the owner's attitude.
Perception – undetermined.
In view of the need to accomplish the mission, there were losses in the crew's ability to properly assess the dangers and risks associated with operating in a region that had restrictions of ceiling, visibility, and turbulence. This condition may have led to a decrease of the situational awareness of the operational environment at the time of landing.
Air traffic planning – a contributor.
All planning and operational demands for this flight were transmitted by the aircraft owner directly to the pilots. The crew only became aware of the exact number of passengers and their respective weights at the time of boarding, something that never occurred when the flights were conducted under the management of the aircraft owner. Such fact contributed to the PR-PMT taking off in incompliance of the weight and balance limits. At the time of the occurrence, there were no requirements established by ANAC for shared ownership aircraft operations.
Decision-making process – a contributor.
The profile of the approach employed revealed difficulties in the crew's perception and analysis of the risks involved in the operation. These difficulties resulted in an inadequate judgment that, consequently, turned into a mistaken decision of trying to land with the aircraft above the maximum weight, in a region that presented restrictions of ceiling, visibility, and moderate turbulence.
Accident investigation:
 |
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Sources:
CENIPA
Revision history:
| Date/time | Contributor | Updates |
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