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| Date: | Wednesday 16 March 2022 |
| Time: | 10:25 UTC |
| Type: |  Sikorsky S-76C++ |
| Owner/operator: | Líder Táxi Aéreo SA |
| Registration: | PR-LCT |
| MSN: | 760723 |
| Year of manufacture: | 2008 |
| Fatalities: | Fatalities: 1 / Occupants: 13 |
| Other fatalities: | 0 |
| Aircraft damage: | Destroyed |
| Category: | Accident |
| Location: | off Baía de Camamu, BA -
 Brazil
|
| Phase: | Approach |
| Nature: | Offshore |
| Departure airport: | Salvador-Deputado Luís Eduardo Magalhães International Airport, BA (SSA/SBSV) |
| Manati NUI Offshore Installation | |
| Investigating agency: | CENIPA |
| Confidence Rating: |  Accident investigation report completed and information captured |
A Sikorsky S-76C++ carrying Petrobras employees was performing a visual traffic for landing on the 9PMM Platform (Manati Platform, Cairu, State of Bahia). On the final approach, there was an excessive increase of the helicopter's rate of descent, and the aircraft collided with the sea surface. The helicopter sustained substantial damage.
The pilot Second in Command (SIC) and eleven passengers suffered minor injuries.
The Pilot in Command (PIC) received fatal injuries.
Contributing factors.
Attention – undetermined.
When focusing his attention on the 9PMM Platform, the SIC is likely to have failed to adequately identify the flight parameters indicative of a destabilized approach, reducing the possibility of a quick and accurate response for correcting such condition. As a result, relevant information made available by the aircraft's instruments may not have been duly observed, hindering one’s selective attention and generating dysfunction of one’s warning system.
Adverse meteorological conditions – undetermined.
The image captured by the 9PMM Platform’s video camera shows the presence of clouds in the region of the accident. However, it was not possible to determine to what extent did the existing meteorological conditions influence the crew's performance during the final approach to the helideck.
Crew Resource Management – a contributor.
The inadequate use of standard call-outs compromised the management of tasks assigned to the pilots. Furthermore, the loss of control of the aircraft was associated with the application of incorrect CRM techniques, including inefficient crosschecking and ineffective coordination.
Work-group culture – undetermined.
One verified that the practice of flight instructors in relation to holding specific briefings was not recurrent for this type of flight, as it was an offshore routine flight for the transport of passengers. Yet, it is possible to infer that holding a specific briefing would have contributed to the mitigation of the risks associated with the operation, when one considers that the flight in question was the first flight of the scheduled fortnight working period for both pilots. Besides, it was the SIC's first flight en route under supervision by a flight instructor.
In addition, it was the first time the SIC was occupying the right-hand seat. Finally, it was the first time the SIC would be performing an approach for a landing on the helideck of the 9PMM Manati Platform.
Handling of aircraft flight controls – a contributor.
Exceedance of the rate of descent to values above 600 feet/min on the final approach for the intended landing on the 9PMM Manati Platform, being rate of descent one of the parameters defined in the aircraft operator’s SOP for a stabilized VFR approach with SK76 helicopters, evidenced an inappropriate handling of the aircraft’s flight controls.
Perception – undetermined.
It is likely that, on the final approach, the exceedance of the parameters recommended for a stabilized approach may have resulted from impairment of the SIC's ability to recognize, organize, understand, and project sensations arising from internal and external stimuli to the aircraft's operating environment, leading to degraded situational awareness, stimulus overload, delayed perception, and “tunnel vision”.
Management planning – a contributor.
The organizational processes adopted within the scope of the operator's SMS were not enough for identifying the dangers posed by the circumstances of that flight. Such dangers were, namely, the fact that it was the first flight of the fortnight working-period for both pilots; the fact that it was the first enroute flight of the SIC being evaluated by a flight instructor; and, the fact that it was first time the SIC was occupying the right-hand seat after
being hired by the aircraft operator.
Support systems – undetermined.
It is possible that the requirements established by the RBAC-61, addressing the subject of pilots' recent experience, have not proven adequate to meeting the minimum level of safety in offshore commercial passenger transport operations with helicopters.
Managerial oversight – undetermined.
The failure to conduct a specific briefing for a flight under the supervision of a flight instructor during the operational experience training phase en route to a Maritime Unit, where the SIC would for the first time make a landing in the right-hand seat as Pilot Flying, indicates that it was a recurring practice among flight instructors not to conduct specific briefings for this type of flight. This reveals a flaw in the company’s managerial supervision,
which may have contributed to the deviations observed on the final approach for landing.
Other (survival equipment) – undetermined.
It is possible that the efficient use of an emergency compressed-air breathing system by the PIC would have increased the likelihood of his escaping the submerged aircraft.
Accident investigation:
 |
|
Sources:
https://romualdomatos.com.br/noticia/26694/aeronave-que-pousou-em-camamu-operava-acima-da-capacidade-maxima-indica-registro.html
https://g1.globo.com/ba/bahia/noticia/2022/03/16/aeronave-com-funcionarios-da-petrobras-faz-pouso-forcado-na-bahia.ghtml
https://www.bahianoticias.com.br/noticia/267006-cenipa-deslocou-equipe-para-investigar-acidente-na-baia-de-camamu.html
https://noticias.uol.com.br/cotidiano/ultimas-noticias/2022/03/16/piloto-de-helicoptero-com-operarios-da-petrobras-morre-apos-pouso-no-mar.htm
https://g1.globo.com/sp/bauru-marilia/noticia/2022/03/16/piloto-de-paraguacu-paulista-que-morreu-em-acidente-de-helicoptero-na-bahia-tinha-25-anos-de-experiencia.ghtml
https://aerossurance.com/helicopters/fatal-offshore-s-76c-loc-i-water-impact-brazil-2022-cenipa-investigation/
https://cdn.jetphotos.com/full/6/50819_1582318918.jpg (photo)
History of this aircraft
Ex N723Y Other occurrences involving this aircraft
| 18 January 2023 | PR-LCT | Líder Táxi Aéreo SA | 0 | Galeão International Airport (GIG/SBGL), Rio de Janeiro, RJ | |
sub |
Location
Images:
Figure: CENIPA
Media:
The Aircraft Commander / Instructor died after a water impact during the first flight of a command course following a loss of control on approach to a NUI. https://t.co/UqzZtKQsUv #helicopter #flightsafety #aviationsafety #humanfactors pic.twitter.com/7ZEuf5SBpL
— Aerossurance (@Aerossurance) August 25, 2024
The Aircraft Commander / Instructor died after a water impact during the first flight of a command course following a loss of control on approach to a NUI. https://t.co/UqzZtKQsUv #helicopter #flightsafety #aviationsafety #humanfactors pic.twitter.com/4l98DWkCaT
— Aerossurance (@Aerossurance) August 25, 2024
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 17-Mar-2022 06:38 | cleberjc | Added |
| 17-Mar-2022 06:40 | harro | Updated [Aircraft type, Operator, Nature, Source, ] |
| 17-Mar-2022 09:06 | RobertMB | Updated [Registration, Operator, Other fatalities, Location, Source, Narrative, ] |
| 17-Mar-2022 09:48 | Anon. | Updated [Registration, Cn, ] |
| 17-Mar-2022 10:07 | RobertMB | Updated [Aircraft type, Source, Narrative, ] |
| 18-Mar-2022 06:25 | cleberjc | Updated [Time, Location, Embed code, ] |
| 18-Mar-2022 09:39 | RobertMB | Updated [Location, ] |
| 18-Mar-2022 18:23 | harro | Updated [Time, Phase, Departure airport, Destination airport, Narrative, ] |
| 07-May-2022 12:30 | Aerossurance | Updated [Aircraft type, ] |
| 07-May-2022 12:31 | Aerossurance | Updated [Narrative, ] |
| 06-Aug-2024 12:57 | ASN | Updated [Destination airport, Narrative, Category, Accident report, ] |
| 06-Aug-2024 14:08 | ASN | Updated [Narrative, Photo, ] |
| 24-Aug-2024 20:37 | Aerossurance | Updated [Source, ] |
| 25-Aug-2024 08:16 | Aerossurance | Updated [Location, Destination airport, Embed code, ] |
| 25-Aug-2024 08:17 | Aerossurance | Updated [Destination airport, Embed code, ] |
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