ASN Wikibase Occurrence # 279675
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| Date: | Wednesday 7 August 2019 |
| Time: | |
| Type: |  Helibras AS 350B-3 |
| Owner/operator: | Amazon State Public Security Secretariat |
| Registration: | PR-EAM |
| MSN: | 4771 |
| Year of manufacture: | 2009 |
| Fatalities: | Fatalities: 0 / Occupants: 6 |
| Aircraft damage: | Substantial |
| Category: | Accident |
| Location: | Flores Aerodrome – SWFN -
 Brazil
|
| Phase: | Take off |
| Nature: | Aerial patrol |
| Departure airport: | Manaus-Aeroclube de Flores Airport, AM (SWFN) |
| Manaus-Aeroclube de Flores Airport, AM (SWFN) | |
| Investigating agency: | CENIPA |
| Confidence Rating: |  Accident investigation report completed and information captured |
The aircraft took off from the Flores Aerodrome (SWFN), Manaus - AM, from a helicopter landing and parking spot, located in front of the UAP hangar, at about 14:10 UTC, to carry out a police mission, with the overflight of the city of Manaus, with two pilots, two tactical air operators and two passengers on board.
As the aircraft was leaving the ground, he started turning to the left. The crew could not control it and there was an acceleration of the spin and height gain.
The aircraft landed abruptly, about 10 m ahead of the take-off point. The main and tail rotor blade did not touch the ground, but the helicopter showed damage to its structure.
The aircraft had substantial damage. All occupants left unharmed.
Contributing factors.
- Control skills – a contributor.
The application of the left pedal to the end of the stroke caused the aircraft to perform an uncontrolled turn to the left, completing 360º in 4.5 seconds. As there was no positive handover of commands, there was a simultaneous and uncoordinated operation of the flight controls, which caused the loss of control in flight and, consequently, a hard landing.
- Training – a contributor.
There was no formal provision for the participation of pilots in training programs and continued training, which made it impossible to maintain the knowledge, skills, and attitudes necessary for effective performance in flight.
- Crew Resource Management – a contributor.
The PIC's attempt to take over the flight controls without communicating to the PF demonstrated poor cabin coordination and made it impossible to regain control of the aircraft.
- Organizational culture – a contributor.
The organizational culture proved to be fragile, since there was no appreciation of training on the part of the managers and members of the UAP, allowing an environment of low adherence to what was foreseen in the operation manuals.
- Memory – undetermined.
It is possible that the PF, for reasons beyond his control, confused the application of the flight controls, due to previous experience in the S300 (Schweizer) aircraft, which may have contributed to the incorrect application of the left pedal.
- Insufficient pilot’s experience – a contributor.
Although the crew had the required experience for the flight, they had little experience in the aircraft model.
The procedural failures observed showed that the total experience of both allowed the operation to go beyond what was foreseen in the operating manuals, as well as contributed to the failures observed in the cabin coordination.
- Organizational processes – undetermined.
The lack of formal processes established concerning organizational supervision regarding the adherence to rules and procedures by the crewmembers may have contributed to the flight being performed on the margin of what was foreseen in the operating manuals.
- Managerial oversight – a contributor.
As noted in the documentation presented, there was no adequate management supervision over the operations, which took place without proper supervision by the organization, allowing procedures prevised in the flight manual to not be complied with.
Accident investigation:
 |
|
Sources:
CENIPA
Location
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 27-Jun-2022 11:45 | harro | Added |
Corrections or additions? ... Edit this accident description
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