ASN Wikibase Occurrence # 204957
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Date: | Tuesday 23 January 2018 |
Time: | 06:02 LT |
Type: | Robinson R44 II |
Owner/operator: | Helisae Helicópteros do Nordeste/Rede Globo TV |
Registration: | PP-HLI |
MSN: | 10026 |
Year of manufacture: | 2003 |
Fatalities: | Fatalities: 3 / Occupants: 3 |
Aircraft damage: | Destroyed |
Category: | Accident |
Location: | Praia de Pina, Recife, Pernambuco -
Brazil
|
Phase: | En route |
Nature: | Survey |
Departure airport: | Recife-Guararapes International Airport, PE (REC/SBRF) |
Destination airport: | Recife-Guararapes International Airport, PE (REC/SBRF) |
Investigating agency: | CENIPA |
Confidence Rating: | Accident investigation report completed and information captured |
Narrative:A Helicopter crashed into the sea at Praia do Pina, in the South Zone of Recife. Three people were on the helicopter. The pilot and one passenger died on the spot, and another occupant died in the hospital.
Contributing factors.
- Aircraft maintenance – a contributor.
The presence of unapproved filler material found on both blades, both on the upper and lower surfaces, with signs of propagation towards the innermost regions indicated that this product was inserted or injected from the outside inwards, consistent with an unapproved repair.
The presence of corrosion found below the original polymer layer and below the unapproved filler material layer showed that the substance was inserted at a date after the beginning of the corrosion process. Debonding was found in all regions that had this filler material, in both blades.
This aircraft was traded more than once, and it was the property of different owners since it was new. Consequently, it had performed maintenance services in various Maintenance Organizations. There was no record of blade repair in the aircraft maintenance records. Therefore, it was not possible to specify in which country, time, place, and circumstances the filler material found in the blades was applied.
According to Brazilian Aviation Regulations the owners or operators were primarily responsible for the airworthiness of the products they operate (IS 39-001 Rev A, item 5.12.2). In addition, they must ensure that maintenance personnel has performed appropriate notes in the aircraft maintenance records logbooks (RBHA 91, item 91.405, letter “b”).
- Managerial oversight – a contributor.
The succession of inspections carried out away from headquarters, for a period exceeding 12 months, in disagreement with the provisions of the IS 145-009B, compromised the establishment of the correct follow-up of the work, thus impairing the proper compliance with the AD 2014-23 -16 and the correct record in the airframe logbook as to the methods effectively used during the inspections of referred guideline.
- Organizational processes – a contributor.
The OM practices involving non-compliance with current legislation, such as the IS 145-009B and the RBAC 145 - section 145.221, denoted the existence of organizational procedures that compromised the safety of the R44 operation.
In addition, the recurring lack of reports on service difficulties in relation to the R44 project, specifically involving the main rotor blades, represented a failure in the OM's communication processes with the ANAC, which compromised the monitoring of the real airworthiness conditions of the project in Brazil and by the FAA, the primary certification authority.
- Training – undetermined.
The absence of recurring training for mechanics may have contributed to a misunderstanding of the maintenance procedures specified in the AD 2014-23-16 and, consequently, resulted in inadequate compliance with these procedures, with the required level of detail.
- Work organization – undetermined.
The accumulation of duties at different hierarchical levels by the same professional, as well as the conflict of roles resulting from this situation, may have impacted the operational safety management process, so that the actions and decisions issued by the chief inspector may have had free acceptance or not have been subjected to some kind of supervision in the OM.
Accident investigation:
|
| |
Investigating agency: | CENIPA |
Report number: | |
Status: | Investigation completed |
Duration: | 2 years and 10 months |
Download report: | Final report |
|
Sources:
https://g1.globo.com/pe/pernambuco/noticia/globocop-cai-na-orla-da-zona-sul-do-recife.ghtml http://www.el-nacional.com/noticias/latinoamerica/dos-muertos-accidente-helicoptero-canal-brasil_219970 http://www.lefigaro.fr/flash-actu/2018/01/23/97001-20180123FILWWW00199-bresil-accident-d-un-helicoptere-de-tv-2-morts.php https://g1.globo.com/pe/pernambuco/noticia/morre-terceira-vitima-da-queda-do-globocop-no-recife.ghtml Media:
Revision history:
Date/time | Contributor | Updates |
23-Jan-2018 20:34 |
Iceman 29 |
Added |
23-Jan-2018 20:50 |
Iceman 29 |
Updated [Aircraft type, Registration, Cn, Source, Embed code] |
23-Jan-2018 21:01 |
Iceman 29 |
Updated [Narrative] |
24-Jan-2018 01:59 |
Geno |
Updated [Time, Source] |
24-Jan-2018 07:23 |
cleberjc |
Updated [Time, Operator, Location, Phase, Departure airport, Destination airport, Source, Embed code, Narrative] |
24-Jan-2018 08:21 |
Iceman 29 |
Updated [Source, Embed code, Photo, ] |
24-Jan-2018 21:08 |
Iceman 29 |
Updated [Embed code] |
01-Feb-2018 19:43 |
davizaum |
Updated [Total fatalities, Source, Narrative] |
03-Feb-2018 07:27 |
cleberjc |
Updated [Operator, Source, Narrative] |
14-Dec-2020 19:45 |
harro |
Updated [Time, Departure airport, Destination airport, Embed code, Narrative, Category, Accident report] |
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