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ASN Wikibase Occurrence # 151303
Last updated: 4 July 2020
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Date:24-NOV-1997
Time:16:26
Type:Silhouette image of generic AS65 model; specific model in this crash may look slightly different
Aérospatiale SA 365N1 Dauphin 2
Owner/operator:Brazilian Government
Registration: PP-ELB
C/n / msn: 6351
Fatalities:Fatalities: 0 / Occupants: 1
Other fatalities:0
Aircraft damage: Substantial
Category:Accident
Location:Rio de Janeiro-Heliponto da Lagoa, RJ -   Brazil
Phase: Take off
Nature:Private
Departure airport:Rio de Janeiro-Heliponto da Lagoa, RJ
Destination airport:Rio de Janeiro-Heliponto da Lagoa, RJ
Investigating agency: CENIPA
Narrative:
The helicopter crashed after it lifted off during a post-maintenance engine test run to check rotor blade balancing.

contributing factors
a. Human Factor
Psychological Aspect - Contributed
Organizational culture of the corporation, still in formation, lacking standardization of procedures and systematization of methods focused on the air activity.
b. Operational Factor
(1). Disabled Supervision - Contributed
The General Coordinator of Air Operations has authorized the pilot to perform the maintenance rotation, even having other pilots with more experience and skills, available on site. The mission required evaluation of the aircraft vibration parameters.
The General Coordinator of Air Operations allowed the pilot to perform, in the week prior to the accident, an experience flight, mission that demands a more refined level of performance.
(2). Disabled Command Application - Contributed
There was a deficiency in the application of the controls because the pilot cut the engine already with the aircraft entering in an abnormal attitude, when he should act in the commands of the cyclic and collective to counteract the longitudinal turn to the left of the aircraft.
(3). Little Flight Experience in the Aircraft - Undetermined
Although there are no defined standards stating the minimum number of flight hours in the aircraft to perform this type of experience flight (the aircraft would not leave the ground, however, in rotary wing aircraft, it is considered "in flight")
from the moment an engine is driven), there is suspicion that the flight experience in the aircraft by the pilot in question would be reduced for that type of mission, considering that there was the need to technically evaluate the services performed by the maintenance.
(4). Poor Planning - Undetermined
There are strong indications that the pilot no longer carries out an adequate pre-flight, as foreseen in the "check-list", where the check of the collective lock before the engines start.
(5). Forgetfulness - Undetermined
There are strong indications that the pilot forgot to check the correct collective lock before starting engine 1.

Sources:

1. http://sistema.cenipa.aer.mil.br/cenipa/paginas/relatorios/rf/pt/pp_elb_24_11_97.pdf

Accident investigation:
cover
  
Investigating agency: CENIPA
Status: Investigation completed
Duration: 3 years
Download report: Final report


Images:


Revision history:

Date/timeContributorUpdates
18-Dec-2012 11:45 TB Added
18-Dec-2012 12:03 TB Updated [Date, Registration, Cn, Operator, Country, Narrative]
11-Mar-2013 19:56 TB Updated [Source, Damage, Narrative]
28-Nov-2016 23:22 Dr. John Smith Updated [Location, Phase, Nature, Departure airport, Destination airport, Source, Narrative]
23-Oct-2018 18:41 Anon. Updated [Photo]
04-Jul-2020 11:53 KagurazakaHanayo Updated [Time, Total occupants, Source, Narrative]
04-Jul-2020 12:02 harro Updated [Location, Phase, Departure airport, Destination airport, Source, Narrative, Accident report, ]

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