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ASN Wikibase Occurrence # 248393
Last updated: 1 March 2021
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Time:15:43 UTC
Type:Silhouette image of generic AS50 model; specific model in this crash may look slightly different
Eurocopter AS 350B2 Ecureuil
Owner/operator:Ceará’s Public Security and Social Defense Dept.
Registration: PP-ENM
C/n / msn: 3333
Fatalities:Fatalities: 0 / Occupants: 5
Other fatalities:0
Aircraft damage: Substantial
Location:Guassussê District, Orós, CE -   Brazil
Phase: En route
Nature:Aerial patrol
Departure airport:Nova Floresta, CE
Destination airport:
Investigating agency: CENIPA
The aircraft took off from Nova Floresta - CE, at about 1535 UTC, in order to participate in a police operation in the region, with two pilots and three Special Equipment Operators (OEE) on board.
With about ten minutes of flight, while accompanying a vehicle, the blades of the main rotor struck low voltage power grid wires. The crew immediately decided to land to assess the helicopter. The maneuver took place successfully.
The aircraft had substantial damage. The five crewmembers left unharmed.

Contributing factors.
- Attention – a contributor.
Maintaining the focus of attention on the vehicle that was being monitored during the flight, contributed to the obstacles in the region were not properly observed by the crew, notably those related to the low voltage power grid.
- Training – undetermined.
The lack of training in CRM may have generated gaps in knowledge, skills and attitudes necessary for the performance of the team, leading to inadequate management of activities related to the crew involved in the accident.
- Crew Resource Management – a contributor.
There was no adequate use of the human resources available in the mission, which resulted in an ineffective management of the tasks assigned to the flight crew, culminating in the failure to visualize the obstacle reached by the blades of the main rotor.
- Piloting judgment – a contributor.
The risks arising from a low altitude operation were not adequately evaluated by the crew, which provided conditions for the collision of the main rotor blades against the low voltage power grid.
- Perception – a contributor.
The operation was characterized by a complex environment, composed by internal and external stimuli that were not properly recognized, leading to a decrease in the crew's situational awareness, directly impacting in the ability to understand and project the risks
involved in this mission.
- Flight planning – a contributor.
The preparation work for the flight was inadequate, especially in aspects related to the operating conditions of the environment in which the flight would be conducted.
- Support systems – undetermined.
Within the scope of the CIOPAER, there was no procedure, in the standards and publications available, defining the minimum altitude for conducting aero police operations.
The absence of criteria to guide airport operations may have contributed to the adoption of inappropriate operating parameters during the flight, favoring the collision with obstacles.
- Managerial oversight – undetermined.
The lack of an effective monitoring of the planning and execution of operational activities may have allowed the adoption of the informal rules of behavior of the crew identified in this occurrence.



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

Revision history:

01-Mar-2021 18:16 harro Added
01-Mar-2021 18:17 harro Updated [Time, Category]

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