On 11 October 2024, an Airbus Helicopters BK117 C-2 (PR-UEA) of the Minas Gerais Military Fire Department took off in poor visibility from a highway interchange near Ouro Preto, Brazil. About 30 seconds later the crew lost sight of the ground. At 56 seconds the helicopter struck terrain near the summit of the Serra do Amolar range. All six people on board were killed and the helicopter was destroyed.
The crew had left Belo Horizonte Pampulha (SBBH) to search for a missing aircraft.
The pilot in command (PIC) reported horizontal visibility of about 100 m, then about 50 m. The helicopter took off at 20:45 UTC.
Investigators estimated visibility at takeoff at about 180 m. RBAC 90 permits takeoff from unregistered sites only in VMC. The rock face came into view about one second before impact.
The EGPWS Colour Change
The EGPWS shows terrain more than 500 ft above the aircraft in red, and terrain from 250 ft below to 500 ft above in yellow. At 34 seconds, climbing through about 4,523 ft, the ridge ahead would have turned from red to yellow. CENIPA considers the PIC may have read this as having climbed above the obstacle. He had only about five hours of instrument flight in IMC, and recurrent training did not cover the EGPWS. The second in command had no instrument rating.
Behind the Flight Deck
The PIC showed signs of possible exhaustion and told colleagues he was not feeling well. Neither pilot attended the 2023 recurrent CRM training, which the unit did not treat as mandatory. The report describes a culture of mission accomplishment and self-sacrifice.
CENIPA rated attitude, piloting judgment, perception and the weather as contributing factors. It cited the decision to take off below the regulatory minima and continue into IMC. It notes the flight lasted about 56 seconds, consistent with the US Helicopter Safety Team's 2021 "56 Seconds to Live" study of inadvertent IMC.
Safety Actions
The fire department suspended flying, added a psychologist, restructured rosters with more rest and set up a Flight Safety Committee. Recurrent training is being realigned with RBAC 90, including CRM for all crew members. CENIPA recommended that ANAC:
1. Share these lessons with Public Aviation Units, stressing mandatory training and an effective SMS (A-144/CENIPA/2024 – 01).
2. Assess SMS audits of these units (A-144/CENIPA/2024 – 02).
Image from the CENIPA report