ASN Wikibase Occurrence # 179821
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| Date: | Wednesday 23 September 2015 |
| Time: | 14:00 UTC |
| Type: |  Bell 206L-3 LongRanger III |
| Owner/operator: | Grupamento Aéreo da Polícia Militar - Secretaria de |
| Registration: | PP-ELA |
| MSN: | 51536 |
| Year of manufacture: | 1991 |
| Fatalities: | Fatalities: 4 / Occupants: 4 |
| Aircraft damage: | Destroyed |
| Category: | Accident |
| Location: | Maceió, Alagoas -
 Brazil
|
| Phase: | Unknown |
| Nature: | Aerial patrol |
| Departure airport: | Zumbi dos Palmares international Airport (SBMO) |
| SNGS | |
| Investigating agency: | CENIPA |
| Confidence Rating: |  Accident investigation report completed and information captured |
The Police helicopter on routine patrol crashed and caught fire. The four occupants died.
Contributing factors.
- Implementation of commands - contributed.
A maneuver with high speed and inclination values would only be possible if there was application in the controls suitable for maintaining the altitude. If the operational limits of the aircraft had been extrapolated, this condition was related to the inappropriate use of the flight controls.
- Warning - undefined.
It is likely that the information processing capability of the pilot flying the aircraft at the time of the accident, particularly related to operational limits, was compromised due to stimuli such as motivation or emotional state.
- Attitude - Undetermined.
The performance of a manoeuvre which may have extrapolated the operational limits of the aircraft may have been an indication of a response to an activity designed without prior planning and supposedly performed by an unauthorised person.
- Communication - Undetermined.
The informal manner in which information was transmitted within the organisation may have compromised the clarity and interpretation of messages, leading to the breaking of current rules and regulations, such as the operation of the helicopter outside its operational limits.
- Working group culture - undetermined.
The supposed operation of the aircraft by a pilot without proper clearance may have been the result of a set of beliefs and values shared by GOA crew members, since the internal culture of that organization was still influenced by the previous experiences of its components, coming from other segments of police activity, and that did not always strengthen the safety culture of air operations.
It should also be noted that the informality may have contributed to the breaking of rules, culminating in the operation of the aircraft, supposedly conducted by pilot without proper clearance.
- Organisational culture - undetermined.
It is possible that the set of informal rules in use at GOA has influenced the interpretation of common facts by the aircraft commander, leading him to believe that the operation of the helicopter by the other pilot would be just a routine action and without greater risk.
- Emotional state - undetermined.
The crew mood was probably changing. The captain due to the stress situation due to his separation and the occupant of the left front seat due to excessive mobilization to become commandant.
These aspects may have compromised the ability to react to the critical flight situation.
- Piloting Trial - contributed.
The pilot failed to adequately assess the theoretical influences related to the performance and flight quality of the aircraft, in performing a low height manoeuvre and with a steep curve.
- Memory - undetermined.
The possibility of the contribution of the behavior known as interference, in this case, characterized by the influence of other helicopter models on the operation of the aircraft involved in the accident, suggests the contribution of this aspect, which maintains a direct relationship with the psychological phenomenon, described by Piaget, called learning transference.
- Perception - contributed.
For various reasons, the psychological state of the pilots inhibited the performance of the processes of recognition and organization of the stimuli received, which could prevent the performance of a maneuver, at low height and with great inclination.
- Flight planning - undetermined.
It is possible that for the accomplishment of that flight there was not the adequate preparation, with the establishment of the correct distribution of the tasks on board.
- Little pilot experience - indeterminate.
The hypothesis that the occupant of the left front seat is in command of the aircraft, without having the model qualification, supposes the contribution of this factor to the event.
- Decision making process - undetermined.
The possibility that the aircraft is under the operation of the left front seat occupant leads to a failure of the commander's decision-making process. This could be associated with the context of informality and the lack of proper consolidation of formal processes within the GOA.
- Organisational processes - contributed.
The lack of use of adequate tools for monitoring crew performance, such as evaluation sheets, revealed the existence of flaws in the formal processes of the organization, compromising the supervision of training flights.
- Support systems - undetermined.
The fact that operational models, such as the Operations Manual (MOP) and Standard Operating Procedures (SOP), were not approved on the date of the accident may have compromised the establishment of adequate and timely supervision of air activities, including training flights.
- Management supervision - contributed.
The informality present in the accomplishment of the air activities, in the scope of the GOA, influenced in the monitoring of the planning phase, competing for the breaking of rules in the conduction of that flight, contributing for the accident.
The possible operation of the aircraft by a pilot without the proper clearance and the presence of two police officers without the valid OEE clearance ratifies the contribution of this aspect.
Accident investigation:
 |
|
Sources:
http://g1.globo.com/al/alagoas/noticia/2015/09/helicoptero-usado-pelo-grupamento-aereo-da-policia-militar-cai-em-maceio.html
http://g1.globo.com/al/alagoas/noticia/2015/09/helicoptero-que-caiu-em-maceio-tinha-licenca-para-voar-ate-2020-diz-anac.html
http://www.rotorspot.nl/historic/pt.php
[LINK NOT WORKING ANYMORE:http://www.hapshack.com/images/NWPd8.jpg]
https://ntsb.gov/_layouts/ntsb.aviation/brief.aspx?ev_id=20150924X44711&key=1&queryId=b67fb2ce-af9b-4034-b983-01dc94630269&pgno=1&pgsize=50
http://sistema.cenipa.aer.mil.br/cenipa/paginas/relatorios/rf/pt/PP-ELA_22_09_2015.pdf
Media:
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 23-Sep-2015 17:02 | junior sjc | Added |
| 23-Sep-2015 19:57 | Iceman29 | Updated [Time, Source, Embed code] |
| 24-Sep-2015 04:02 | rafaelboaventura | Updated [Operator, Phase, Nature] |
| 24-Sep-2015 04:02 | cleberjc | Updated [Time, Aircraft type, Operator, Location, Nature, Source, Narrative] |
| 19-Oct-2015 12:46 | Aerossurance | Updated [Time, Nature, Departure airport, Source, Narrative] |
| 10-Aug-2020 16:48 | KagurazakaHanayo | Updated [Time, Destination airport, Source, Narrative] |
| 10-Aug-2020 16:53 | harro | Updated [Narrative, Accident report, ] |
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