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ASN Wikibase Occurrence # 194780
Last updated: 23 April 2021
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Date:12-APR-2017
Time:18:25 LT
Type:Silhouette image of generic AS50 model; specific model in this crash may look slightly different
Helibras AS 350B2 Esquilo
Owner/operator:Heli-Rio Taxi Aereo
Registration: PT-YZM
Msn: AS2831
Fatalities:Fatalities: 1 / Occupants: 2
Other fatalities:0
Aircraft damage: Written off (damaged beyond repair)
Category:Accident
Location:off Praia de Itacoatiara, Niterói, RJ -   Brazil
Phase: En route
Nature:Passenger - Non-Scheduled/charter/Air Taxi
Departure airport:Recreio Helipad, Rio de Janeiro, RJ (SDRE)
Destination airport:Recreio Helipad, Rio de Janeiro, RJ (SDRE)
Investigating agency: CENIPA
Narrative:
The helicopter took off from the Recreio’s Helipad (SDRE), Rio de Janeiro - RJ, at about 21:05 UTC, on a local flight, with a pilot and a passenger on board.
After about, when flying over Itacoatiara beach, located in the city of Niterói, under adverse weather conditions and in a night flight, the helicopter struck the water surface.
The aircraft was destroyed.
The pilot suffered fatal injuries and the passenger was unharmed.

Contributing factors
- Attitude – a contributor.
The performance of the flight in which this accident occurred, without proper planning, under adverse weather conditions at night, without the pilot being properly qualified and without the helicopter being properly certified to perform flights under IFR rules, characterized an attitude of complacency in relation to the responsibilities assigned to the aircraft commander in Article 169 of the CBA and in section 91.3 of the RBHA n° 91 with regard to flight safety, which contributed to this occurrence.
- Adverse meteorological conditions – undetermined.
It is possible that the conduct of the flight under adverse weather conditions, by a pilot not qualified to operate IFR, in an aircraft not certified for this type of operation, contributed to a spatial disorientation and resulted in a CFIT.
- Organizational culture – a contributor.
The way the air activity was conducted in the Company and the way in which the flight of this accident occurred was prepared and carried out, demonstrated a low adherence to the principles of flight safety, characterized by the application of informal rules, informally institutionalized, and pointed out the fragility of organizational culture with regard to flight safety.
- Disorientation – undetermined.
It is likely that the pilot (not qualified in IFR flight) was disoriented during the turns made in the Itacoatiara region while trying to maintain himself in visual flight conditions over the sea, at night and in an adverse weather conditions.
In this scenario, it is possible that he inadvertently placed the aircraft on a controlled descending flight path, without realizing the imminence of the impact against the sea.
- Flight indiscipline – a contributor.
The impossibility of flying under IFR flight rules and the persistence of continuing to the planned destination flying at low altitude in adverse weather conditions characterized the violations of items 3.4.3 of the ICA 100-4 and 5.1.4 of the ICA 100-12 as contributing factors to this accident.
- Piloting judgment – a contributor.
There was an inadequate assessment of the real need to fly under those unsafe operating conditions, as well as the decision to proceed to the intended destination even in the face of deteriorating weather conditions, facts that also contributed to this occurrence.
- Motivation – undetermined.
Considering the personal involvement linked to the purpose of the flight, it is possible that the decisions to make it under those unsafe operational conditions and to proceed to the intended destination even in the face of deteriorating weather conditions have been influenced by a high motivation, considering that his intention was to “rescue” the passenger's son, with whom the pilot had a friendship bond.
- Flight planning – a contributor.
Considering the reports that there was no preparatory action for the flight and that, in this context, issues related to bad weather, night flight, secondary routes and an emergency landing were not discussed, it was concluded that the preparation work carried out by the pilot for the flight was not adequate, characterizing the planning as a contributing factor for this occurrence.
- Decision-making process – a contributor.
The context in which the accident occurred demonstrated that inadequate judgments about the factors involved in the intended operation compromised the quality of the commander's decision-making process and resulted in inappropriate choices that contributed to the occurrence, object of this investigation.
- Organizational processes – a contributor.
The Company's inefficiency in the management of people and processes, characterized by the lack of monitoring and supervision of the activities of its employees and the absence of an adequate outline of organizational procedures important to the maintenance of operational safety, resulted in the decision to start and conduct a flight without careful planning, under adverse weather conditions, with inadequate crew and aircraft and for reasons predominantly personal to those involved, circumstances that favored the occurrence of this accident, object of this investigation.
- Managerial oversight – a contributor.
The lack of monitoring and supervision of planning and execution of activities, at the operational level, reflected inadequate supervision by the organization's management, which also contributed to the flight being carried out without adequate safety conditions.

Sources:

https://extra.globo.com/noticias/rio/helicoptero-cai-em-itacoatiara-bombeiros-buscam-por-primo-de-rosinha-garotinho-rv1-1-21201462.html
https://g1.globo.com/rio-de-janeiro/noticia/corpo-de-piloto-de-helicoptero-e-encontrado-por-bombeiros-em-itacoatiara-rj.ghtml
CENIPA

Accident investigation:
cover
  
Investigating agency: CENIPA
Status: Investigation completed
Duration: 4 years
Download report: Final report
Location

Media:


Revision history:

Date/timeContributorUpdates
13-Apr-2017 13:59 Aerossurance Added
13-Apr-2017 14:00 Aerossurance Updated [Date]
13-Apr-2017 16:58 Black Typhoon Updated [Aircraft type, Registration, Cn, Operator, Total fatalities, Source, Narrative]
13-Apr-2017 16:59 harro Updated [Narrative]
13-Apr-2017 19:27 Iceman 29 Updated [Embed code]
14-Apr-2017 06:03 cleberjc Updated [Location, Phase, Nature, Destination airport, Embed code]
14-Apr-2017 07:07 Aerossurance Updated [Aircraft type, Location]
14-Apr-2017 14:02 Aerossurance Updated [Location]
23-Apr-2021 07:30 harro Updated [Time, Location, Departure airport, Destination airport, Source, Narrative, Category, Accident report]

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