ASN Wikibase Occurrence # 221737
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| Date: | Monday 11 February 2019 |
| Time: | 14:05 UTC |
| Type: |  Bell 206B JetRanger II |
| Owner/operator: | RQ Helicópteros – Serviços Aéreos Especializados |
| Registration: | PT-HPG |
| MSN: | 1705 |
| Year of manufacture: | 1975 |
| Fatalities: | Fatalities: 2 / Occupants: 2 |
| Aircraft damage: | Destroyed |
| Category: | Accident |
| Location: | Rodovia Anhanguera, São Paulo, SP -
 Brazil
|
| Phase: | En route |
| Nature: | Illegal Flight |
| Departure airport: | Royal Palm Plaza Helipad, SP (SSQW) |
| TV Bandeirantes Helipad, SP (SDBH) | |
| Investigating agency: | CENIPA |
| Confidence Rating: |  Information verified through data from accident investigation authorities |
During a passenger transport flight between the Royal Palm Plaza Helipad (SSQW), Campinas to the Bandeirantes Helipad (SDBH), São Paulo, Brazil, the aircraft had an engine failure in flight and an unsuccessful attempt to landing was made between the Anhanguera (SP-330) and the SP-021 (Rodoanel Mário Covas) Highways.
Close to the ground, a truck-type vehicle that traveled on the Highway access lane hit the aircraft.
The truck had substantial damage to the cabin. The aircraft was destroyed.
The truck driver left unharmed. The pilot and passenger of the helicopter died on the spot.
Contributing factors.
- Control skills – undetermined.
There may have been an inadequacy in the use of the controls, which may have caused the aircraft not to reach the chosen area during the autorotation, culminating with the attempt to land on the place where the accident occurred.
- Attitude – a contributor.
The conduct, by the operator, of the maintenance actions demonstrated that there was an attitude of non-observance of important procedures for the decision to perform a flight safely.
In addition, the pilot disregarded the terms described in the RBAC 135 related to the air taxi mode, according to which he could not take this type of flight.
- Organizational culture – a contributor.
The conduct presented at the company related to the use of the aircraft, as well as maintenance, reflected flaws in the organization's culture with regard to operational safety, since it was possible to observe a set of practices adopted that generated unacceptable risks for the execution of the activity.
- Flight indiscipline – a contributor.
The pilot-owner of the RQ Serviços Aéreos Especializados Ltd. performed a flight that went beyond the limits of the operator's authorization and for which he was not qualified.
In addition, the pilot-owner operated the aircraft with the TBO of the engine compressor module expired, which made it non-airworthy.
- Piloting judgment – a contributor.
There was an inadequate evaluation by the pilot of the parameters related to the operation of the aircraft during the execution of the autorotation and landing maneuver, which contributed to the outcome of the occurrence.
- Aircraft maintenance – a contributor.
The reinstallation of the compressor module with the expired TBO, as well as the subsequent release of the aircraft for return to service, showed inadequacy of the maintenance procedures performed by the OM.
Failure to comply with the maintenance program, particularly in relation to the calendar interval for changing the engine oil and reinstalling the compressor module with the expired TBO, demonstrated the non-adherence of the operator, who is primarily responsible for maintenance, in relation to the requirements of Continued Airworthiness, which contributed to this accident.
- Motivation – undetermined.
The financial return that the flight would bring to the company, in a time of shortage of contracted flights, may have motivated the pilot-owner to assume it, even though it was not certified for this.
- Decision-making process – a contributor.
The operational conditions in which the flight was performed, demonstrated that there was no critical analysis of the entire scenario involved, observing the possible risks and consequences inherent to the decision to execute it.
- Organizational processes – a contributor.
There was an inefficiency, both on the part of the operator and the maintenance organization, in monitoring and executing the maintenance processes. The operator was aware of the fact that installing the compressor module without performing the overhaul, as well as exceeding the oil change intervals, contradicted the maintenance program provided for the aircraft engine, thus making it “not airworthy ”. Likewise, the fact that the OM approved the return to service of the aircraft without proof of overhaul of the compressor module, contradicted the maintenance program prevised to the aircraft engine, since the helicopter would be “non-airworthy”.
Accident investigation:
 |
|
Sources:
1. https://g1.globo.com/sp/sao-paulo/noticia/2019/02/11/ricardo-boechat-jornalista-morre-aos-66-anos-em-queda-de-helicoptero-em-sp.ghtml
2. https://g1.globo.com/sp/sao-paulo/noticia/2019/02/12/video-mostra-acidente-com-helicoptero-que-matou-boechat-e-piloto.ghtml
3. https://www.bbc.co.uk/news/world-latin-america-47196268
4. http://aerossurance.com/helicopters/b206b-truck-unairworthy-engine/
Media:
B206B Hit by Truck in Forced Landing after 16 Months of Operation with Unairworthy Engine : engine oil tube blocked so no 2 engine bearing failed https://t.co/1bS9gIGp9B pic.twitter.com/EcjtasFvxR
— Aerossurance (@Aerossurance) November 8, 2020
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 11-Feb-2019 16:58 | eholiveira | Added |
| 11-Feb-2019 17:16 | RobertMB | Updated [Aircraft type, Cn] |
| 11-Feb-2019 17:21 | harro | Updated [Operator] |
| 11-Feb-2019 17:37 | RobertMB | Updated [Source] |
| 11-Feb-2019 17:44 | RobertMB | Updated [Operator, Source] |
| 11-Feb-2019 18:11 | harro | Updated [Operator] |
| 11-Feb-2019 19:15 | NaamanHeckert | Updated [Departure airport, Destination airport] |
| 11-Feb-2019 20:29 | renatopmeireles | Updated [Embed code] |
| 11-Feb-2019 22:00 | Aerossurance | Updated [Source, Narrative] |
| 11-Feb-2019 22:02 | Aerossurance | Updated [Source] |
| 11-Feb-2019 23:37 | Iceman 29 | Updated [Embed code] |
| 11-Feb-2019 23:38 | Iceman 29 | Updated [Embed code, Narrative] |
| 12-Feb-2019 18:12 | Anon. | Updated [Source, Narrative] |
| 12-Feb-2019 18:51 | cleberjc | Updated [Time, Operator, Other fatalities, Location, Nature, Destination airport, Source, Narrative] |
| 12-Feb-2019 18:51 | harro | Updated [Operator] |
| 13-Feb-2019 06:38 | cleberjc | Updated [Narrative] |
| 13-Feb-2019 20:12 | cleberjc | Updated [Embed code] |
| 04-Nov-2020 15:24 | harro | Updated [Time, Nature, Departure airport, Destination airport, Narrative, Category, Accident report] |
| 08-Nov-2020 15:59 | Aerossurance | Updated [Source, Accident report] |
| 08-Nov-2020 16:11 | Aerossurance | Updated [Embed code] |
| 24-Jun-2021 20:08 | Lucas.L | Updated [Location, Nature, Departure airport, Destination airport, Source, Embed code] |
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