ASN Wikibase Occurrence # 191861
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| Date: | Sunday 4 December 2016 |
| Time: | 18:30 UTC |
| Type: |  Robinson R44 II |
| Owner/operator: | Helicopter Charter Service do Brasil Taxi Aereo |
| Registration: | PR-TUN |
| MSN: | 12560 |
| Year of manufacture: | 2008 |
| Fatalities: | Fatalities: 4 / Occupants: 4 |
| Aircraft damage: | Destroyed |
| Category: | Accident |
| Location: | São Lourenço da Serra, São Paulo -
 Brazil
|
| Phase: | Approach |
| Nature: | Illegal Flight |
| Departure airport: | Osasco-HBR Heliport, SP (SSUB) |
| São Lourenço da Serra-Recanto Beija-Flor, SP | |
| Investigating agency: | CENIPA |
| Confidence Rating: |  Accident investigation report completed and information captured |
An Robinson R44 helicopter going from Osasco to São Lourenço da Serra in the São Paulo region in crashed 2km away from the destination. The four occupants died in the crash. A rescue helicopter dispatched to the accident scene reportedly had to return to base due to low visibility and rain in the region.
Four people died last saturday afternoon of a helicopter crash in São Lourenço da Serra, a city in the southwest of the Metropolitan Region of São Paulo. The victims are the bride Rosemere Nascimento Silva, 32, who was on her way to her wedding, her brother, a pregnant photographer and the pilot of the aircraft, according to the Fire Department.
The helicopter went to the Recanto Beija-Flor, in São Lourenço, where the wedding would take place, and fell at around 4:00 p.m. - the time of the beginning of the celebration. Rosemere, who was a nursing assistant, was to marry Udirley Marques Damasceno, 34. She intended to surprise him and his family, arriving by helicopter at the ceremony.
Contributing factors.
- Anxiety – undetermined.
Reactions caught by the camera suggested signs of high anxiety from the passengers,which may have promoted self-imposed pressure on the part of the pilot, contributing to the decision to complete the flight as scheduled.
- Attention – undetermined.
It is possible that relevant information provided by aircraft instruments has not been observed by the pilot, whose focus could be on the GPS information. Such attention shifting may have favored disorientation as it reduced the proper perception of flight parameters.
- Attitude – a contributor.
The flight rules, as well as the guidelines contained in the Flight Manual, were not properly observed by the pilot. In that sense, the continuation of the flight denoted an excessive confidence of the crewmember in his capacity, to the detriment of the adverse conditions present.
- Training – undetermined.
It is possible that the low exposure to adverse weather conditions affected the ability to identify, evaluate and respond promptly to the situation experienced on the flight that caused the accident.
These difficulties may have been exacerbated, due to the failures related to the pilot training process, which did not have standardized evaluation actions and corrective actions according to the level of performance of each student.
- Adverse meteorological conditions – a contributor.
Adverse weather conditions seriously impaired the pilot's spatial orientation in the visual aspect, since he had no visual references that could guide his trajectory.
- Disorientation – a contributor.
Upon entering IMC flight conditions, there was loss of visual references and awareness of the position of the aircraft, causing loss of control.
- Fatigue – undetermined.
Flights performed on the day before and on the day of the accident, coupled with the short time available for rest and possible sleep deprivation to meet such demands, may have induced the pilot to fatigue and degraded his performance during the flight.
- Piloting judgment – a contributor.
The pilot opted to join in adverse weather conditions and to continue the flight, without having technical qualification, specific training and aircraft certified for IFR conditions.
- Work organization – undetermined.
The routine performed by the pilot increased the conditions of susceptibility to fatigue, due to the few opportunities for adequate rest and sleep. This context may have hampered the pilot's performance during critical flight management.
- Perception – a contributor.
Visibility restrictions and consequent loss of visual references promoted favorable conditions for pilot disorientation and loss of control of the aircraft, due to an inaccurate perception of the helicopter's behavior and its position in relation to the terrain.
- Flight planning – a contributor.
The lack of knowledge of the route operational conditions, mainly regarding the meteorological conditions, denoted a poor planning.
- Decision-making process – a contributor.
The decision to proceed with the flight in degraded meteorological conditions denoted an imprecise assessment of the conditions in that operational context, setting up a failed decision-making process.
- Flight Indiscipline – a contributor.
The pilot did not comply with the visual flight rules when entering adverse weather conditions, allowing the occurrence of spatial disorientation.
Accident investigation:
 |
|
Sources:
1. https://g1.globo.com/sao-paulo/noticia/noiva-que-morreu-em-acidente-tinha-sonho-de-ir-de-helicoptero-ao-casamento.ghtml
2. https://noticias.r7.com/sao-paulo/helicoptero-que-levava-noiva-ao-casamento-cai-na-grande-sao-paulo-04122016
3. http://sao-paulo.estadao.com.br/noticias/geral,noiva-que-seguia-para-casamento-e-mais-3-pessoas-morrem-em-queda-de-helicoptero,10000092497
4. https://g1.globo.com/sao-paulo/noticia/pericia-investigara-queda-de-helicoptero-que-matou-noiva-em-sp.ghtml
5. https://aeromagazine.uol.com.br/artigo/helicoptero-envolvido-em-acidente-em-sao-paulo-nao-tinha-registro-de-taxi-aereo_3031.html (Illegal Flight)
6. http://www.dailymail.co.uk/news/article-4671124/Moment-bride-killed-minutes-wedding-Brazil.html
Images:
The bride just before the accident
Media:
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 05-Dec-2016 06:57 | acspotbr | Added |
| 05-Dec-2016 06:59 | harro | Updated [Aircraft type, Cn, Operator, Other fatalities] |
| 05-Dec-2016 10:36 | LAURENCE | Updated [Source, Embed code, Narrative, Photo, ] |
| 05-Dec-2016 16:46 | Geno | Updated [Source] |
| 01-Jan-2017 19:26 | cleberjc | Updated [Time, Location, Departure airport, Destination airport] |
| 06-Jul-2017 19:59 | MarkStep | Updated [Source] |
| 06-Jul-2017 22:51 | Iceman 29 | Updated [Embed code] |
| 23-Apr-2020 13:18 | Awat | Updated [Source] |
| 23-Apr-2020 13:22 | harro | Updated [Narrative, Accident report, ] |
| 24-Jun-2021 20:08 | Lucas.L | Updated [Time, Nature, Departure airport, Destination airport, Source, Embed code, Category] |
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