Investigation into Collision of Truck with Police Helicopter (AS350B2, PR-CJD, Brazil)
The two occupants and the truck driver suffered minor injuries. Three other occupants of the police helicopter and two passengers in the truck were unharmed. The Brazilian accident investigation agency CENIPA issued their safety investigation report on 9 February 2022.
The tasking was to support a vehicle checkpoint. The helicopter had landed on one side of a two lane, 23 m wide, turning area between two carriageways, surrounded by overhead electric cables and lamp posts.
The aircraft had remained on the ground for about 30 minutes. The tail was marked with a single traffic cone at that time.
The collision occurred after the team had re-boarded the helicopter and was was rotor-running, preparing for departure. The crew believed that as turning vehicles would be travelling slowly and because the helicopter was “visible” and “noisy” it was not necessary for traffic to be stopped.
The driver of a turning truck, approaching from behind the helicopter, did not notice the helicopter and struck the main rotor.
Although not commented upon by CENIPA, the truck appears to have been carrying barrels of biological waste, some of which appear to have been damaged.
The unit operated under RBHA 91 Sub-Part K regulations for Public Security / Civil Defence Operations as a ” Small Civil Aviation Service Provider”. 91.961 states in relation to operating from ad hoc urban sites:
It is incumbent upon the [Public Security / Civil Defence] Agency to establish training programs and standard operating and flight safety procedures in order to guide the conduct of crews under such special conditions.
The aircraft commander, who had a Commercial Pilots Licence, had 1142 hours flying experience, the co-pilot, who held a private Pilots Licence, 201. Neither had been formally trained in operating from public roads and the unit’s training manual did not cover the topic. They had only done this the day before for the first time.
The unit also had no CRM training programme and recording irregularities were found in the aircraft’s technical records.
CENPA Contributory Factors Analysis and Safety Recommendations
- Attitude: There was an inadequate assessment of the risks associated with the [start-up] while vehicles and people could move freely around the helicopter…which revealed a complacent attitude towards important procedures for the safety.
- Training: The lack of a formally implemented training program resulted in organizational failures that led to…operation on a public road, without the proper isolation of the area.
- Communication: …communication between the crewmembers and the crew on the ground (police checkpoint) did not involve the dissemination of relevant information about the operation.
- Crew Resource Management: There was inefficiency in the use of human resources available…
- Team dynamics: The inadequate evaluation of all parameters related to that operation…contributed to an inefficient performance by the team.
- Flight planning: The need to interrupt the traffic of vehicles, of people, and the [value] of carrying out a detailed briefing involving the crew and ground crew (police checkpoint) were not adequately considered.
- Management planning: [two occupants, wearing crewman's 'monkey' harness but not strapped into their seats] were thrown out of the helicopter [which] revealed the inadequacy in the planning… with regard to the provision and control of the use of equipment.
- Organizational processes: The inefficiency…planning, documentation of standards and procedures, risk management and operational safety management led to failures in supervision, in monitoring the performance of crewmembers and in the design of important organizational procedures for the maintenance of safety.
- Managerial oversight: The non-conformities pointed out in relation to the manuals and procedures that should guide air operations, the finding that the helicopter had flown with overdue inspections, as well as the lack of records on the completion of the planned training, affected the performance of the crew and compromised the operations safety.
Four Safety Recommendation were raised by CENPIA on the organisation of the unit.
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