Power Line Colision- Eurocopter EC120B Colibri

7/25/2019 Power Line Colision- Eurocopter EC120B Colibri

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RELATRIO DE

SEGURANA GPIAA

Investigao de Ocorrncia de Acidente

GPIAA SAFETY REPORT

Accident Occurrence Investigation

09/ACCID/2013

FINAL

RELATRIO FINAL HOMOLOGADO PELO DIRETOR DO GPIAAFINAL REPORT APPROVED BY GPIAA DIRECTOR

30-06-2015 (LVARO NEVES)

Coliso c om cabo s || Powerl in e co l isio nMarmelete

Monchiqu e, Portugal

18 de dezembr o 2013, 13:50 UTC

2013, December 18th, 13:50 UTC

Euroco pter EC120B Co l ibr i

HELIPORTUGAL / CS-HEX


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RELATRIO FINAL DE ACIDENTE || ACCIDENT FINAL REPORT N 09/ACCID/2013

Gabinete de Preveno e Investigao de Acidentes com Aeronaves

Pag. 2 / 49

Nota:a fotografia na capa deste relatrio foi tirada por Pedro Becken (retirado do stio airliners.net)

Note:the photo on this report cover was taken by Pedro Becken (from airliners.net site)


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RELATRIO DE SEGURANA DE ACIDENTE

ACCIDENT SAFETY REPORT

HELIPORTUGAL

EUROCOPTER EC120B COLIBRI

CS-HEXCOLISO COM CABOS || POWERLINE COLISION

MARMELETE

MONCHIQUE

PORTUGAL

18 de dezembro 2013 - 13:50 UTC

2013, December 18th- 13:50 UTC

RELATRIO FINAL DE ACIDENTE

ACCIDENT FINAL REPORT09/ACCID/2013


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Publicao || Published by:

GPIAAGabinete de Preveno e Investigao de Acidentes com Aeronaves

Portugal Safety Accident Investigation BoardEndereo || Postal Address Office:

Praa Duque de Saldanha, 314

1050-094 Lisboa

Portugal

Telefones || Telephones:

+ 351 21 273 92 30

+ 351 915 192 963 / +351 272 739 255 (24 horas) / 707 284 637 (707 AVI OES)

(Notificao de incidentes e acidentes)

Fax + 351 21 273 92 60

Email: [email protected]

Internet: www.gpiaa.gov.pt

No interesse de aumentar o valor da informaocontida nesta publicao permitido baixar,imprimir, reproduzir e distribuir este materialreconhecendo o GPIAA - Gabinete de Prevenoe Investigao de Acidentes com Aeronavescomo a fonte. No entanto, direitos de autorsobre o material obtido a partir de outrasagncias, indivduos ou organizaes privadas,pertencem a essas agncias, indivduos ouorganizaes. Onde for pretendido usar o seumaterial ser necessrio contact-losdiretamente.

In the interest of enhancing the value of theinformation contained in this publication youmay download, print, reproduce and distributethis material acknowledging the GPIAA -Gabinete de Preveno e Investigao deAcidentes com Aeronaves as the source.However, copyright in the material obtainedfrom other agencies, private individuals ororganizations, belongs to those agencies,individuals or organizations. Where you want touse their material you will need to contact themdirectly.

Governo de Portugal

Secretaria de Estado da Infraestruturas, Transportes e Comunicaes

GPIAA 2015


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PREFCIO || FOREWORD

A investigao tcnica um processoconduzido com o propsito da prevenode acidentes o qual inclui a recolha eanlise da informao, a determinao dascausas e, quando apropriado, a formulaode recomendaes de segurana.

Safety investigation is a technical processaiming to accidents prevention and

comprises the gathering and analysis ofevidences, in order to determine the causesand, when appropriate, to issue safetyrecommendations.

Em conformidade com o Anexo 13 Conveno sobre Aviao CivilInternacional, Chicago 1944, com oRegulamento (UE) N 996/2010 doParlamento Europeu e do Conselho, de20/10/2010, e com o n 3 do art. 11 doDecreto-lei N 318/99, de 11 de Agosto, ainvestigao tcnica no tem por objetivo oapuramento de culpas ou a determinaode responsabilidades.

In accordance with Annex 13 to theInternational Civil Aviation OrganisationConvention (Chicago 1944), EU RegulationNr. 996/2010 from the EuropeanParliament and Council (20th OCT 2010)and article 11 n 3 of Decree-Law n 318/99(11th AUG 1999), the sole purpose of thisinvestigation is to prevent aviationaccidents. It is not the purpose of any suchinvestigation process and the associatedinvestigation report to apportion blame orliability.

Este relatrio foi preparado, somente, paraefeitos de preveno de acidentes.

The only aim of this technical report is tocollect lessons which may help to preventfuture accidents.

Este relatrio foi publicado em duas lnguas,Portugus e Ingls.

This report was published in twolanguages, Portuguese and English.

Em caso de discrepncias, o texto em

Portugus ter prevalncia.

In the event of any discrepancy between

these versions, the Portuguese text shallprevail.


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NDICE || TABLE OF CONTENTS

TTULO || TITLE PGINA || PAGE

PREFCIO || FOREWORD ........................................................................................................................... 5

NDICE || TABLE OF CONTENTS .................................................................................................................. 6

SINOPSE || SYNOPSIS ................................................................................................................................. 9

ABREVIATURAS || ABREVIATIONS ........................................................................................................... 11

1. INFORMAO FACTUAL || FACTUAL INFORMATION .......................................................................... 12

1.1. Histria do Voo || History of the flight ............................................................................................. 12

1.2. Leses || Injuries to persons ............................................................................................................. 17

1.3. Danos na Aeronave || Damage to aircraft ........................................................................................ 17

1.4. Outros Danos || Other damage ........................................................................................................ 18

1.5. Pessoas Envolvidas || Personnel information................................................................................... 18

1.5.1. Piloto || Pilot .................................................................................................................................. 18

1.5.2. Passageiros || Passengers .............................................................................................................. 19

1.6. Aeronave || Aircraft information ...................................................................................................... 19

1.6.1. Generalidades || General .............................................................................................................. 19

1.6.2. Massa e Centragem || Mass and balance ...................................................................................... 22

1.6.3. Performance || Performance ......................................................................................................... 22

1.6.4. Manuteno || Maintenance ......................................................................................................... 23

1.7. Informao meteorologia || Meteorological information................................................................ 23

1.8. Ajudas navegao || Aids to navigation ......................................................................................... 24

1.8.1. Rastro de Radar || Radar trace ...................................................................................................... 24

1.9. Comunicaes || Communications ................................................................................................... 24

1.10. Informao do aerdromo || Aerodrome information .................................................................. 24

1.11. Registadores de Voo || Flight recoders .......................................................................................... 24

1.12. Destroos e informao sobre os impactos || Wreckage and impact information ....................... 25

1.12.1. Obstculos || Obstacles ............................................................................................................... 25

1.12.2. Exame aos destroos || Wreckage Examination. ........................................................................ 26

1.13. Informao mdica e patolgica || Medical and pathological information ................................... 26

1.13.1. Piloto || Pilot ................................................................................................................................ 261.13.2. Termografista || Thermographer................................................................................................ 26


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1.13.3. Observador || Observer ................................................................................................................ 27

1.14. Incndio || Fire ............................................................................................................................... 27

1.15. Sobrevivncia || Survival aspects ................................................................................................... 27

1.15.1. Emergency Locator Transmitter (ELT) || Emergency Locator Transmitter (ELT) ......................... 281.15.2. Assentos || Seats ......................................................................................................................... 28

1.16. Ensaios e pesquisas || Tests and research ...................................................................................... 29

1.17. Organizao e gesto || Organizational and management information ........................................ 29

1.17.1. A Heliportugal || The Heliportugal .............................................................................................. 29

1.18. Informao adicional || Additional information ............................................................................. 29

1.18.1. Acidentes anteriores e recomendaes || Previous accidents and recommendations .............. 30

1.18.1.1. Acidente 05/ACCID/GPS/99 || Accident 05/ACCID/GPS/99 ..................................................... 30

1.18.1.2. Acidente 25/ACCID/2005 || Accident 25/ACCID/2005 ............................................................. 30

1.18.1.3. Acidente 23/SUM/2008 || Accident 23/SUM/2008 ................................................................. 31

1.18.1.4. Incidente 19/INCID/2008 || Incident 23/SUM/2008 ................................................................ 31

1.18.1.5. Acidente 34/ACID/2009 || Accident 34/ACID/2009 ................................................................. 32

1.18.1.6. Acidente 15/SUM/2009 || Accident 15/SUM/2009 ................................................................. 33

1.18.1.7. Incidente 12/INCID/2011 || Incident 12/INCID/2011 ............................................................... 33

1.18.1.8. Resumo das ocorrncias anteriores || Summary of previous occurences ............................... 34

1.19. Tcnicas de investigao utilizadas || Useful or effective investigation techniques...................... 34

2. ANLISE || ANALYSIS............................................................................................................................ 35

2.1. O Helicptero || The helicopter ........................................................................................................ 35

2.1.1. Descrio geral || General Description .......................................................................................... 35

2.1.2. Motor || Engine ............................................................................................................................. 36

2.1.3. Caixa de transmisso principal || Main Gearbox (MGB) ............................................................... 36

2.1.4. Ps do rotor principal || Main rotor blades ................................................................................... 36

2.1.5. Comandos de voo || Flight controls .............................................................................................. 37

2.2. A carga de trabalho || The workload ................................................................................................ 37

2.3. O piloto || The pilot .......................................................................................................................... 37

2.4. Heliportugal || Heliportugal .............................................................................................................. 38

2.5. Labelec || Labelec ............................................................................................................................. 39

2.6. Linhas eltricas || Powerlines ........................................................................................................... 41

2.7. Corta cabos || Cable cutters ............................................................................................................. 44

3. CONCLUSES || CONCLUSIONS ........................................................................................................... 45

3.1. Evidncias || Findings ....................................................................................................................... 45


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3.2. Causas || Causes ............................................................................................................................... 46

3.3. Factores Contributivos || Contributing factores ............................................................................... 46

4. RECOMENDAES DE SEGURANA || SAFETY RECOMENDATIONS .................................................... 47

4.1. Aes de segurana postas em prtica || Safety action following the accident .............................. 474.2. Recomendaes de segurana || Safety recomendations ............................................................... 49


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SINOPSE || SYNOPSIS

Data do acidente || Date of accident

18-12-2013 14:27UTC1

Aeronave || Aircraft

Eurocopter Colibri EC120B, Reg CS-HEX

Local do acidente || Site of accident

371730N / 0083825W 4.5NM Monchique

Proprietrio || Owner

Heliportugal

Tipo de voo || Type of flight

Inspeo de linhas || Power line inspection

Operador || Operator

Heliportugal

Pessoas a bordo || Persons on board

Tripulantes || Flight crew: 1

Passageiros || Passengers: 2

Leses || Injuries

Mortes || Fatal: 1

Feridos graves|| Serious: 2

No dia 18 de Dezembro de 2013, descolou s

13:50 UTC do heliporto de Monchique, ohelicptero Eurocopter EC120B Colibri, matrculaCS-HEX, para um voo de inspeo de linhaseltricas na zona de Marmelete. A bordo seguiaum piloto e dois passageiros que constituamtripulao tcnica de inspeo de linhas.

On December the 18th, took-off from

Monchique heliporto at 13:50 UTC, thehelicopter Eurocopter EC120B Colibri,registration CS-HEX, for a power line inspectionflight at Marmelete area. One pilot and twopassengers as power line inspection technicalcrew were on board.

Cerca de 30 minutos de voo aps a descolagem,o helicptero embatia numa linha eltrica quecruzava superiormente a linha que estava a serinspecionada.

Around 30 minutes after take-off, the helicopterhit a power line crossing above the one beinginspected.

O acidente provocou dois feridos graves, ummorto e a destruio da aeronave.

The accident caused two serious injuries, onefatal and the aircraft destruction.

Nem o piloto nem os passageiros conseguiramver atempadamente a linha eltrica com quechocaram.

Neither the pilot nor the passengers were able tosee on time the power line they crashed.

1

Todas as horas referidas neste relatrio, salvo indicao em contrrio, so horas UTC. Naquela poca do ano, em Portugalcontinental, a hora local era igual hora UTC. || All time referred in this report, unless otherwise specified, are UTC time. At thatseason in Portugal, local time was the same as UTC time


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A linha eltrica no tinha bolas de balizageminstaladas.

The power line did not have installed signallingballs.

O GPIAA emitiu duas recomendaes desegurana. Uma destinada EDP Distribuiovisando a balizagem de linhas eltricas. Outradestinada Heliportugal recomendando ainstalao de corta cabos em helicpteros aoperar em inspeo de linhas.

GPIAA issued two safety recommendations. Oneaddressed to EDP Distribuio aiming atsignalling power lines. Another addressed toHeliportugal recommending the installation ofcable cutters in helicopters operating ininspection lines.


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ABREVIATURAS || ABREVIATIONS

AGL Acima do nvel do terreno || Above Ground Level

COTA Certificado de Operador de Trabalho Areo || Aerial Work Operating Certificate

EDP Distribuio EDP Distribuio - Energia SA || Portugal Electricity Distribution Company

GPIAA Gabinete de Preveno e Investigao de Acidentes com Aeronaves || SafetyInvestigation Authority

hPa Hectopascal || Hectopascal

IGEOE Instituto Geogrfico do Exrcito || Portuguese Army Geographic Institute

INAC Instituto Nacional de Aviao Civil || National Civil Aviation Authority

Kph Quilmetros por hora || Kilometer per hour

Kts Ns || Knots

MTOM Massa mxima descolagem || Maximum take-off mass

NM Milha Nutica || Nautic Mile

PT Posto de transformao || Electric Substation

REN Rede Eltrica Nacional || National Power Newtork

STC Certificado Suplementar de tipo || Supplemental Type Certificate

UTC Tempo Universal Coordenado || Universal Time Coordinated

VMC Condies meteorolgicas visuais || Visual Meteorologic Conditions


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1. INFORMAO FACTUAL || FACTUAL INFORMATION

1.1.Histr ia do Voo || History of the f l ight

H mais de uma dcada que a empresaHeliportugal tinha um contrato parafornecimento de meios areos com a empresaLabelec Estudos, Desenvolvimentos eActividades Laboratoriais, SA (ora em dianteLabelec) no mbito da inspeo de linhaseltricas. data do acidente a Heliportugaloperava em todo o pas com dois helicpteros,sendo um deles, o helicptero acidentado.

For over a decade, the Heliportugal companyhad a contract for the supply of aircraft withLabelec Estudos, Desenvolvimentos eActividades Laboratoriais, SA (hereinafterLabelec) under the inspection of power lines.At the time of the accident the Heliportugaloperated throughout the country with twohelicopters, being one of them, the accidentedhelicopter.

A equipa de trabalho constituda por 1 piloto e2 tcnicos da Labelec.

The working team consists of one pilot and twotechnicians from Labelec.

No EC120B a posio do piloto direita. Dolado esquerdo, frente, ia sentado o tcnico deinspeo visual, doravante designado porobservador. As suas principais tarefas so aobservao de obstculos e orientao dostrabalhos. Atrs, do lado esquerdo, seguia otcnico de inspeo termogrfica, doravantedesignado por termografista. A sua principal

funo era funcionar com o equipamento deinspeo. Para isso tem que monitorizar 1 ecr, 1computador e manipular 1joystick.

In the EC120B the pilot position is on the right.On the left side, in the front, was sitting thevisual inspection technic, hereinafter observer.Its main tasks are the observation of obstaclesand direction of the work. Behind, in the leftside, was the thermography inspection technic,hereinafter thermographer. Its main functionwas to operate the inspection equipment. To

achieve this he had to monitor 1 screen, 1computer and manipulate 1 joystick.

A equipa estava a trabalhar na regio do Algarvedesde 16-12-2013, 2 feira.

The team was working on Algarve region sinceMonday, 2013 December 16th.

Na manh do dia 18 de dezembro descolaram doheliporto de Loul para terminar os trabalhos nazona de Portimo e Alvor. Tinha sido planeadoabastecer e almoar no heliporto de Monchique.

As condies meteorolgicas iriam piorar para ofinal da tarde pelo que iria ser realizado apenasmais um voo.

On the morning of December 18 th they took offfrom Loul heliport to finish the work in the areaof Portimo and Alvor. It had been planned torefuel and have lunch at Monchique heliport. .

Weather conditions would get worse for the lateafternoon so it would be carried out only onemore flight.

s 13:50, aps abastecimento, o CS-HEXdescolou de Monchique para efetuar inspees alinhas de mdia tenso na zona de Marmelete(figura n 1).

At 13:50, after refuelling, the CS-HEX took offfrom Monchique to perform inspections ofmedium voltage lines in Marmelete area (picturen 1).


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figura 1 || picture n 1

O helicptero chegou vertical do posto detransformao (PT) na zona de Marmelete e teveque entrar em espera durante cerca de 10minutos devido a uma anomalia defuncionamento do equipamento de inspeoque obrigou a reiniciar o sistema. A espera foiefetuada a cerca de 500 ps AGL.

The helicopter arrived at the substation (PT)vertical in Marmelete area had to go on hold forabout 10 minutes due to a malfunction in theinspection equipment that forced to restart thesystem. The wait was performed at about 500feet AGL.

Passado esse tempo o problema ficousolucionado, comeando a inspeo. A partir

desta altura o voo passou a realizar-se a baixavelocidade e baixa altitude.

After this time the problem was solved and theinspection started. From this point the flight

began to take place at low speed and lowaltitude.

Durante cerca de 30 minutos o CS-HEX percorreua linha de 15 kV assinalada a azul na figura n 2.O helicptero voava sempre com a linha do seulado esquerdo.

For about 30 minutes the CS-HEX roamed the 15kV line marked in blue in the picture n 2. Thehelicopter flew always with the line on the left.

Pouco antes do acidente tinha retomado ainspeo no PT A e seguiam ao longo dospostes P01, P02, P03, P04 P05e P06,

conforme indicado na figura n 2 a amarelo.

Shortly before the accident it had resumed theinspection on "PT A and followed along thepoles "P01", "P02", "P03", "P04", P05 and

"P06", as shown in yellow on picture n 2.


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O poste P06 ficava num local elevado e nelehavia uma derivao da linha, direita, a descerat ao PT B.

The pole P06 was in a high place and itcontained a line derivation, to the right,descending to PT B

Quando as linhas a inspecionar seguiam por umterreno bastante inclinado (figura n 3) eranorma efetuar a inspeo em sentido contrrio,ou seja, a subir.

When the lines to be inspected followed by avery steep terrain (picture n 3) it was normal toperform the inspection in the opposite direction,i.e. to climbing.


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figura 3 || picture n 3 (Fonte || Source: IGEOE)

Assim, quando o CS-HEX chegou ao poste P06,o termografista anunciou PAUSA, indicando ao

piloto que a gravao tinha sido suspensa epodia abandonar o seguimento da linha.

So, when CS_HEX got to the post "P06", thethermographer announced "PAUSE" indicating tothe pilot that the recording had been suspendedand he could abandon the line following.

Nesse momento o piloto voltou direita edesceu o vale uma velocidade, segundo o piloto,prxima dos 50 Kts.

At this point the pilot turned right and wentdown the valley, according to the pilot, at anapproximate speed of 50 Kts.

O percurso provvel seria manter a linha do ladodireito at estar abeam do PT B e de seguidafazer uma volta de 180 graus pela direita e seguiros postes, P07, P08, P09, P10, P11 e

P12, levando-o de volta ao P06, conformeindicado a amarelo esbatido.

The likely route would keep the line on the rightand fly till abeam PT B and then do an 180degrees right turn and follow the poles, "P07"P08 "," P09 "," P10 "," P11 "and" P12 "leadingthem back to "P06", as indicated in light yellow.

O CS-HEX embateu numa linha de 60 kV,indicada a vermelho, que cruzava superiormentea que seguia. O ponto do embate estrepresentado por uma estrela amarela.

The CS-HEX hit a 60 kV line, indicated in red,crossing above the one being inspected. Thehitting point is represented by a yellow star.

Esta linha no foi vista atempadamente pelopiloto nem pelo termografista. No se recordamde nenhum alerta feito pelo observador.

This line was not seen in time neither by the pilotnor the thermographer. They dont rememberany warning made by the observer.


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Da coliso resultaram danos catastrficos naaeronave fazendo com que o piloto perdesse ocontrolo do mesmo. O helicptero rodou 2 ou 3vezes sobre si e despenhou-se cerca de 70metros frente numa zona com rvores,representado na figura por um helicpteroamarelo.

The collision resulted in a catastrophic damageto the aircraft causing the pilot to lose controlover it. The helicopter rolled 2 or 3 times aroundits axis and crashed about 70 meters ahead in anarea with trees, shown in figure by a yellowhelicopter.

A cauda separou-se da restante estrutura assimque o estabilizador horizontal se prendeu naslinhas. As ps do rotor principal ficaramdestrudas ao embater nas rvores. Apesar dasrvores terem fornecido algum amortecimento,o contacto com o solo foi muito violento.

The tail detached from the rest of the structurewhen the horizontal stabilizer hit the lines. Themain rotor blades were destroyed as soon asthey hit the trees. Although the trees haveprovided some cushioning, the contact with theground was very violent.

A notificao do acidente foi feita s 14:27, por

telefone, para o nmero nacional de emergncia(112), por trs madeireiros que trabalhavam nolocal. Alm de dar o alarme, os madeireirosocorreram ao local onde, com algumadificuldade e receio de incndio, retiraram osocupantes dos escombros e levaram-nos paraum local seguro.

The notification of the accident was made at

14:27, by telephone, to the national emergencynumber (112) for three loggers working on site.Besides giving the alarm, the loggers went to thecrash site and, with some difficulty and with fearof fire, removed the occupants from thewreckage and took them to a safe location.

O observador que ocupava o lugar esquerdo frente no sobreviveu ao acidente. Os doisferidos continuaram a receber assistncia dos

trs madeireiros at chegada dos BombeirosVoluntrios de Monchique, pelas 14:45 numaviatura de emergncia mdica que saiu doquartel s 14:30.

The observer who occupied the front left seatdid not survive the accident. The two woundedcontinued to receive assistance from the three

loggers until the arrival of the Fire Brigade ofMonchique, by 14:45 in a medical emergencyvehicle that left the barracks at 14:30.

Pelas 14:42 o GPIAA foi avisado do acidentetendo deslocado uma equipa de investigaopara o local. O INEM continuou a prestarassistncia s vtimas e pelas 15:33 foi acionadoum meio areo para o local.

By 14:42 the GPIAA was notified of the accidenthaving moved an investigation team to the site.The Medical Emergency team continued toprovide assistance to victims and by 15:33 an airambulance was deployed to the place.

O termografista foi evacuado para o Hospital dePortimo. O piloto acabaria por seraerotransportado para o Hospital de Santa Maria(Lisboa). O bito do observador foi confirmadopelo mdico s 17:30.

The thermographer was evacuated to thePortimo Hospital. The pilot was eventuallyflown to the Hospital of Santa Maria (Lisbon).The death of the observer was confirmed by thedoctor at 17:30.


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1.2.Leses || Injur ies to persons

Leses

Injuries

Tripulantes

Crew

Passageiros

Passengers

Outros

Others

Mortais / Fatal: 0 1 0

Graves / Serious: 1 1 0

Ligeiras-Nenhumas / Minor-None: 0 0

1.3.Danos na Aeronave || Damage to aircraft

O helicptero caiu cerca de 70 metros frentedo ponto onde embateu nas linhas num terrenobastante inclinado e arborizado por eucaliptos ealgumas rvores de copa redonda que foramfundamentais para amortecer o contacto com osolo e impedir que o helicptero deslizasse ourolasse pela encosta abaixo.

The helicopter crashed about 70 meters ahead ofthe point where it hit the lines in a steep, slopedand wooded ground with eucalyptus and someround top trees that were fundamental tocushion the contact with the ground and preventthe helicopter slid or rolled downhill .

Com o embate a cauda separou-se da estruturaprincipal. As ps do rotor principal ficaramdestrudas (figura n 4). A cabine ficou bastante

danificada.

With the clash the tail separated from the mainstructure. The main rotor blades were destroyed(picture n 4). The cabin was badly damaged.

A aeronave foi classificada como destruda. The helicopter was classified as destroyed.


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1.4.Outros Danos || Other damage

A linha de 60 kV foi cortada pelo acidente. The 60 kV power line was cut by the accident.

1.5.Pessoas Envolvidas || Personnel information

1.5.1. Piloto || Pi lot

O piloto, sexo masculino, 29 anos, nacionalidade

Portuguesa, era piloto na Heliportugal desde deabril de 2013 e fazia inspees de linhas desdeessa altura.

The pilot, male, 29 years old, Portuguese

nationality, was a pilot at Heliportugal since April2013 and did power line inspections since then.

Dos seus documentos pessoais foram recolhidasas seguintes referncias:

Of their personal documents the followingreferences were collected:


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Identificao || Identification Piloto || Pilot

Licena || License:

Validade || Valid until:

Qualificaes || Qualifications:

ltimo exame mdico || Last medical check-up:

Limitaes || Limitations:

CPL(H)

30-09-2014

AS350/EC130, HU269, KA32, EC120B, IR(ME), FI(H)

11-10-2013

Nil

Experincia de voo || Flight experience Total || Total No tipo || On type

Horas de voo totais || Total flight hours:

ltimos 90 dias|| Latest 90 days:

ltimos 28 dias || Latest 28 days:

ltimos 7 dias || Latest 7days:

ltimas 24 horas || Latest 24 hours:

1307:05

21:05

08:40

08:40

04:35

13:55

08:40

08:40

08:40

04:35

1.5.2. Passageiros || Passengers

Neste tipo de operao, os passageiros tm umafuno a bordo de inspeo tcnica de linhas.Pertenciam a uma equipa com anos de

experincia neste tipo de trabalho. Otermografista exercia funes desde 1998 (15anos), enquanto o observador fazia desde 1999(14 anos).

In this kind of operation, the passengers have anon-board technical function of power lineinspection. They were part of a team with years

of experience in this kind of job. Thethermographer performed his duties since 1998(15 years), while the observer did since 1999 (14years).

1.6.Aeronave || Aircraft information

1.6.1. General idades || General

A aeronave era um helicptero ligeiromonomotor, de motor de turbina, de patins,com rotor principal de trs ps, com capacidadepara 5 pessoas e uma Massa Mxima Descolagem (MTOM) de 1715 kg (figura n 5).

The aircraft was a single-engine light helicopter,turbine engine, skids, with three blades in themain rotor, with 5 seats and a Maximum Take-off Mass (MTOM) of 1715 kg (picture n 5).


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O EC120B maioritariamente construdo a partirde materiais compsitos e tem um rotor decauda tipo Fenestron, tornando-o umhelicptero particularmente silencioso.(Apndice J da FAA parmetros de rudosobrevoo = 78,7 dB SEL, 6,7 dB SEL abaixo doslimites Stage 2). Certificado pelos padres FAR27, o EC120B tambm possui assentosresistentes coliso e um sistema decombustvel resistente coliso.

The EC120B is mostly built from compositematerials and has a Fenestron tail rotor,

making it a particularly quiet helicopter. (FAAAppendix J flyover noise signature = 78.7 dB SEL,6.7 dB SEL below Stage 2 limits). Certified to FAR27 standards, the EC120B also features crash-resistant seats and a crash-resistant fuel system.

O combustvel usado era JETA1. JETA1 fuel was used.

figura 5 || picture n 5 (Fonte || Source: airliners.net, Lus Carlos Oliveira)


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Figura 6 || picture n 6 (Dimenses externas || external dimensions)

O helicptero tinha a bordo equipamento determografia e laser devidamente aprovado porSTC prprios.

The helicopter had on board equipment ofthermal imaging and laser duly approved by STC.

A aeronave com a matrcula CS-HEX tinha todasas Licenas e Certificados vlidos e tinham sidocumpridas as aes de manuteno, conformeprograma aprovado pela Autoridade

Aeronutica, no havendo anomalia ourestries operao da aeronave e seussistemas e apresentava as seguintes referncias:

The aircraft with the registration CS-HEX had allLicenses and Certificates valid, all maintenanceactions were completed as program approved bythe Aeronautical Authority, with no anomaly or

restrictions on the operation of the aircraft andits systems and had the following references:

Referncia || Reference Clula || Airframe Motor || Engine Rotor || Rotor

Fabricante || Manufacturer Eurocopter Turbomeca Eurocopter

Modelo || Model EC120B Arrius 2F M281

N de Srie || Serial No 1183 34255 C622A0101056

Ano || Year 2000 -- --

Horas Voo || Flight hoursDesde novo || Since new

Desde reviso || Since revision5318:50231:35

233:27123:27

5318:50231:35

Aterragens/Ciclos || Landings /Cycles 5063 -- --

ltima Inspeo 17-12-2013 17-12-2013 17-12-2013


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1.6.2. Massa e Centragem || Mass and balance

O helicptero tinha descolado de Monchiquecom 1650 Kg para um mximo de 1715Kg.

The helicopter took off from Monchique with1650 Kg for a 1725 Kg maximum.

A centragem longitudinal e lateral estava dentrodos limites estabelecidos pelo fabricanteconforme indicado na figura n 7.

The longitudinal and lateral balance was withinthe limits set by the manufacturer as shown inpicture n 7.

figura 7|| picture n 7

1.6.3. Performance || Performance

A performance do helicptero garantia umaoperao segura. As condies de massa ealtitude de densidade na zona de operaopermitiam inclusive efetuar estacionrio fora deefeito de solo.

The helicopter performance guaranteed a safeoperation. The mass and density altitudeconditions in the operation zone included out ofground effect hovering performance.

Velocidade nunca a exceder: 278 Kph(150 Kts) Never exceed speed: 278 Kph (150 Kts)

Velocidade de cruzeiro: 223 Kph(120 Kts) Cruise speed: 223 Kph (120 Kts)

Razo de subida: 5.84 m/s (1,150 ps/min) Rate of climb: 5.84 m/s (1,150 ft/min)


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1.6.4. Manuteno || Maintenance

As ltimas manutenes foram realizadas pelaHelisuporte, Organizao de Manuteno

aprovada com a licena Part145 PT.145.019.Foram realizadas as seguintes tarefas principais.

The last maintenance were performed byHelisuporte, approved Maintenance

Organisation Part 145 PT.145.019. The followingmain tasks were performed.

Em 02-09-2013, inspeo das 100h fuselagem,inspeo anual fuselagem, inspeo de100h/anual ao motor, cumprir com EASA AD2011-0182 R1 e cumprir com CTI 81-15.

On 2013, September 02ndperform 100h airframeinspection, perform 100h/annual airframeinspection, perform 100h/annual engineinspection, comply with EASA AD 2011-0812 R1and comply with CTI.81-15.

Em 02-12-2013, inspeo mensal fuselagem. On 2013, December 02nd perform monthlyairframe inspection.

Em 17-12-2013, cumprir com EASA AD 2010-0026-Eparag(1).

On 2013, December 13th comply with EASA AD2010-0026-E parag (1).

O programa de manuteno da aeronave foicumprido na integra.

The aircraft maintenance program has beenaccomplished in full.

1.7. Informao meteorolgica || Meteorological information

As condies locais eram VMC. O vento estavacalmo e a presso local era de 1027 hPa. A

visibilidade era superior a 10km. O cu estavalimpo.

The local conditions were VMC. The wind wascalm and the local pressure was 1027 hPa. The

visibility was greater than 10km. The sky wasclear.

A estao meteorolgica com informaoaeronutica mais prxima era Faro (LPFR) a cercade 35 NM (65 Km) do local do acidente.

The nearest meteorological station withaeronautical information was Faro (LPFR) about35 NM (65 Km) from the crash site.

LPFR 181100Z 26004KT CAVOK 15/11 Q1029LPFR 181130Z 26007KT 9999 FEW030 16/11 Q1029LPFR 181200Z 25007KT 9999 FEW030 16/11 Q1028

LPFR 181230Z 25007KT 9999 FEW030 16/11 Q1027LPFR 181300Z 26008KT 9999 FEW025 17/11 Q1027LPFR 181330Z 28009KT 9999 FEW025 17/11 Q1027


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1.8.Ajudas navegao || Aids to navigat ion

1.8.1. Rastro de Radar || Radar trace

O voo foi realizado sem plano de voo econsequentemente com o transponder emstandby.

The flight was carried without a flight plan andconsequently with the transponder in standby.

Mesmo que tivesse sido realizado com otransponder ligado, devido morfologia doterreno e ao tipo de operao realizada no seriapossvel obter qualquer rastro de radar a partirdo aeroporto de Faro.

Even if it had been carried out with thetransponder on due to the terrain morphologyand the type of operation would not be possibleto obtain any radar trace from Faro airport.

1.9.

Comunicaes || Communicat ions

O piloto efetuou contacto rdio com o operadordo Centro de Meios Areos (CMA) antes dadescolagem. No houve nenhum contacto rdiodepois da descolagem.

The pilot made radio contact with the AerialCenter (CMA) operator prior to departure. Therewas no radio contact after take-off.

O voo decorria em espao areo no controlado(classe G) e a muito baixa altitude. No tinhasido submetido plano de voo.

The flight was carried under uncontrolledairspace (class G) and at very low altitude. Aflight plan has not been submitted

1.10. Informao do aerdromo || Aerodrome information

O helicptero descolou do heliporto deMonchique. Este heliporto normalmenteutilizado para voos de evacuao mdica e basede combate a incndios.

The helicopter took off from the heliport ofMonchique. This heliport is usually used formedical evacuation flights and fire fighting base.

Dispe de um operador de CMA que, entreoutras funes, opera o rdio. A frequncia do

CMA no gravada.

It has a CMA operator that, among otherfunctions, operates the radio. The CMA

frequency is not recorded.

1.11. Registadores de Voo || F l ight recorders

A aeronave no estava equipada comregistadores de voo, por no ser obrigatrio paraeste tipo de aeronave.

The aircraft was not equipped with flightrecorders, as it is not mandatory for this type ofaircraft.


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1.12. Destroos e informao sobre os impactos || Wreckage and impact

information

Os destroos estavam concentrados numa

pequena rea. A cauda estava separada daestrutura tendo ficado pouco destruda. Arestante estrutura estava destruda com partesespalhadas numa pequena rea.

The wreckage was concentrated in a small area.

The tail was separated from the structure havingbeen a little destroyed. The remaining structurewas destroyed with portions spread over a smallarea.

As condies meteorolgicas que se seguiram aoacidente fizeram com que no fosse possvelfazer a recolha do Manual de Voo, da folha demassa e centragem nem de alguns haverespessoais.

Weather conditions that followed the accidentmade it not possible to recover the flightmanual, the mass and balance sheet and somepersonal belongings.

A figura n 8 mostra a estrutura principal dohelicptero tal como encontrada pelos serviosde emergncia.

Picture n 8 shows the main body of thehelicopter as found by the emergency services.


1.12.1. Obstculos || Obstacles

Vindo do NE, ao atingir a rea do acidente, ohelicptero tinha que atravessar trs linhaseltricas de 60 kV, que atravessavam um vale

com cerca de 500 m de largura, distanciando-secerca de 100 m da rea do acidente.

Coming from the NE, when reaching the crasharea, the helicopter had to cross 3 electrical 60kV power line, crossing a valley with about 500

m wide and spaced about 100 m from the crasharea.


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1.12.2. Exame aos destroos || Wreckage Examinat ion.

Os destroos foram enviados para o hangar deinvestigao do GPIAA em Viseu, onde foram

examinados pelo Investigador Responsvel.Como no apresentavam qualquer evidncia deproblemas tcnicos, a Eurocopter, Turbomeca, ea BEA consideram no proceder a qualqueravaliao de anlise aos destroos.

The wreckage where sent to the GPIAAinvestigation hangar in Viseu, where they were

examined by the Investigator in Charge. As didnot show any evidence of technical problems,the Eurocopter, Turbomeca, and the BEAconsidered not evaluating any analyses to thewreckage.

O exame no mostrou danos preexistentes quepoderiam explicar o acidente.

The examination showed no pre-existing damagethat could explain the accident.

O motor debitava potncia no momento doimpacto, e o sistema de controlos de voo dohelicptero estavam operativos.

The engine delivered power upon impact, andthe controls system of the helicopter wereoperative.

1.13. Informao mdica e patolgica || Medical and pathological

information

1.13.1. Piloto || Pi lot

O piloto sofreu amputao do p direito, fraturado mero e cbito esquerdo alm de vrias

escoriaes.

The pilot suffered amputation of the right foot,fracture of the left humerus and ulna and several

abrasions.

Esteve cerca de um ms internado e foisubmetido a vrias cirurgias. Foi submetido a umprograma de reabilitao com a finalidade detreino e adaptao prtese.

He was about a month hospitalized andunderwent several surgeries. He underwent arehabilitation program with the purpose oftraining and adaptation to the prosthesis.

Regressou ao servio areo ao fim de 7 meses. He returned to flight duty after 7 months.

1.13.2. Termograf ista || Thermographer

O termografista sofreu leses na cervical, ps,mos, pernas, bao, pulmo esquerdo, 5costelas, 6 vrtebras e maxilar. Foi operado 4vezes.

The thermographer was injured in the neck, feet,hands, legs, spleen, left lung, 5 ribs, 6 vertebraeand jaw. Was operated 4 times.

data de concluso deste relatrio ainda notinha regressado ao servio.

On completion of this report had not yetreturned to service.


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1.13.3. Observador || Observer

O observador teve morte imediata. Foi realizadaa autpsia.

The observer died instantly. An autopsy wasperformed.

Sofreu leses traumticas crnio-meningo-enceflicas, torcicas, abdominais e dosmembros.

He suffered traumatic skull, brain,meningoencephalitis thoracic, abdominal andlimb injuries.

No foram encontrados vestgios de lcool nemsubstncias estupefacientes ou psicotrpicas.

There were no traces of alcohol or narcotic drugsor psychotropic substances.

O observador morreu como resultado das forasdurante o impacto.

The observer died as a result of the forces duringimpact.

1.14.

Incndio || F ire

Do acidente resultou um pequeno foco deincndio tendo sido imediatamente extinto pelosBombeiros Voluntrios de Monchique.

The accident resulted in a small ignition whichwas immediately extinguished by Monchiquefire-fighters.

1.15. Sobrevivncia || Survival aspects

Os trs ocupantes usavam os cintos desegurana apertados. A resistncia estrutural dacabina no foi suficiente para limitar as lesessofridas. Aps ter perdido o controlo ohelicptero chocou contra umas rvores antesde bater no solo.

The two occupants wore their seatbeltsfastened. The structural strength of the cabinwas not enough to limit injuries suffered. Theclash in the ground was very violent despite thisbeing soft.

A pronta assistncia dos trs madeireiros foifundamental para a sobrevivncia dos doisferidos e constituiu um ato assinalvel deregisto.

The prompt assistance of the three loggers wasessential to the survival of the two wounded andwas a remarkable act of registration.

O piloto e os tcnicos no usavam capacete deproteo.

The pilot and the technicians did not wearprotective helmet.


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1.15.1. Emergency Locator Transmitter (ELT) || Emergency Locator

Transmitter (ELT)

O ELT no ativou no momento do impacto, no

entanto, este no teve incidncia sobre osaspetos de sobrevivncia.

The ELT did not activate upon impact, however,

this had no incidence on the survivabilityaspects.

1.15.2. Assentos || Seats

Os bancos esto equipados com um sistema deabsoro de choque vertical, com vista a atenuaras foras de impacto (at 20G).

The seats are equipped with a system of verticalshock absorption, designed to mitigate theimpact forces (up to 20G).

Os bancos suportaram o embate. As suas

estruturas principais no sofreram fraturas. Noentanto apresentam algumas deformaeslaterais conforme indicado na figura n 9.

The seats hold the crash. Its main structures did

not suffer fractures. However they show somelateral deformations as shown in picture n9.

O assento direito recuou 4 cm desde a suaposio inicial. O assento esquerdo no sofreuqualquer deslocamento vertical.

The right seat recoils 4 cm from its initialposition. The left seat suffered no verticaldisplacement.

Os cintos de segurana estavam apertados eaguentaram o impacto.

The seat belts were fastened and withstood theimpact.



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1.16. Ensaios e pesquisas || Tests and research

No se tendo verificado qualquer falha dematerial ou mau funcionamento de qualquer

sistema, no se considerou necessrio procedera ensaios mecnicos de qualquer componente.

As there was no material failure or malfunctionof any system, it was not considered necessary

to carry out mechanical tests of any component.

As pesquisas foram dirigidas para as reas dapreparao dos trabalhos e planeamento do vooem inspees de linhas eltricas.

Researches were focused to work preparationand flight planning during power lineinspections.

1.17. Organizao e gesto || Organizat ional and management

information

1.17.1. A Heliportugal || The Hel iportugal

A Heliportugal encontrava-se devidamenteautorizada e certificada pelo INAC para efetuarinspees a linhas eltricas.

The Heliportugal was duly authorized andcertified by INAC to operate in power lineinspections.

Todas as suas operaes eram reguladas pelasnormas especificadas no respetivo Manual deOperaes, nos manuais das aeronaves e outralegislao emitida pelas autoridades

aeronuticas, de acordo com o Certificado deOperador de Trabalho Areo (COTA) emitidopelo INAC.

All operations were covered by rules specified inits Operations Manual, aircraft manuals andother legislation issued by the aeronauticalauthorities, according to the Aerial Work

Certificate (COTA) issued by INAC.

Os trabalhos de manuteno das aeronaveseram executados pelos tcnicos da empresa,devidamente qualificados, e por empresascertificadas e contratadas para o efeito.

The aircraft maintenance was performed by thecompany technicians properly qualified and

certified and by contracted certified companiesfor this purpose.

O CS-HEX era usado pela Heliportugal e Labelecapenas para este tipo de misso, portanto, o

helicptero estava apenas equipado comcontrolos do lado direito. Os pedais esquerdosestavam na posio mas desligados.

The CS-HEX is used by Heliportugal and Labeleconly for this type of mission, therefore, the

helicopter was only equipped with right controls.The left pedals were in position but they weredisconnected.

1.18. Informao adicional || Addit ional information

No existem informaes complementares areferir.

There is no further information to refer.


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1.18.1. Acidentes anter iores e recomendaes || Previous accidents and

recommendations

A coliso com cabos um acidente aeronutico

recorrente aos quais esto mais sujeitoshelicpteros a operar em trabalho areo.

The collision with cables is a recurring aircraft

accident to which are more likely occurhelicopters operating in aerial work.

Apresenta-se uma lista de algumas ocorrnciasem Portugal.

It presents a list of some events in Portugal.

1.18.1.1. Acidente 05/ACCID/GPS/99 || Accident 05/ACCID/GPS/99

Em 21/04/1999 o helicptero McDonell Douglas369E, a operar para a Heliportugal estava a

efetuar inspeo de linhas eltricas ao servio daEDP.

On 1999, December 21stthe helicopter McDonellDouglas 369E, operating for Heliportugal was to

make inspection of electrical lines serving theEDP.

O helicptero embateu numa linha de 60 kV quecruzava superiormente a linha de 15 kV queestava a ser inspecionada. Essa linha no estavaassinalada na carta de rede da Labelec.

The helicopter hit a line of 60 kV crossing abovethe 15 kV line that was being inspected. This linewas not marked in the Labelec network card.

A aeronave, que no estava equipada com cortacabos, ficou destruda.

The aircraft, not equipped with cable cutters,was destroyed.

O piloto faleceu. Um ocupante teve lesesgraves na coluna vertebral. O outro ocupantesofreu leses de menor gravidade.

The pilot died. An occupant had severe spinalinjuries. The other occupants suffered minorinjuries.

Foram feitas cinco recomendaes de seguranapara a alterao procedimentos da Heliportugal,para a modificao dos equipamentos para olugar de trs libertando o observador, para otreino em MCC, para a instalao de corta cabose para a atualizao dos dados de massa ecentragem.

Five safety recommendations were made toHeliportugal amendment procedures, for themodification of equipment to the back seatreleasing the observer, for training in MCC, forcable cutters installations and for the upgrade ofthe mass and balance data.

1.18.1.2. Acidente 25/ACCID/2005 || Accident 25/ACCID/2005

Em 24-07-2005, um helicptero AS350B2 aoperar para a Helisul estava a participar nocombate a um fogo florestal na zona deMoimenta da Beira.

On 2008, July 16th, by 19:37, an helicopterAS350B2 operating for Helisul was participatingin fighting a forest fire in Moimenta da Beirazone.


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Aps a primeira largada de gua o helicpterocolidiu com os patins numa linha de mdiatenso, no balizada, que no foram detetadosdurante o reconhecimento.

After the first water drop the helicopter collidedwith skids in a medium voltage line, unmarked,which were not detected during recognition.

O helicptero ficou preso pelos cabos e rodou. Opiloto perdeu controlo do mesmo e cortou omotor. O helicptero no tinha corta cabos esofreu danos significativos.

The helicopter was trapped by cables and rolled.The pilot lost control of it and cut the engine.The helicopter did not have installed cablecutters and suffered significant damage.

O piloto no sofre leses apesar de no usarcapacete.

The pilot was unarmed although he did not weara protective helmet.

Foram emitidas trs recomendaes desegurana: instalao de corta cabos; sinalizaodas linhas elctricas; sensibilizao das brigadas

helitransportadas acerca de obstculos.

Three safety recommendations were issued:cable cutter installation; power line signalling;awareness of airborne brigades about obstacles.

1.18.1.3. Acidente 23/SUM/2008 || Accident 23/SUM/2008

Em 16-07-2008, pelas 19:37, um helicpteroAS350B2 a operar para a Helibravo estava aparticipar no combate a um fogo florestal nazona de Ribeira de Pena. Aps efetuar 7 largadasde gua, o piloto foi recolher a brigada aterrandonum local apropriado.

On 2008, July 16th, by 19:37, an helicopterAS350B2 operating for Helibravo wasparticipating in fighting a forest fire in Ribeira dePena zone. After making seven drops of water,the pilot was landing to pick up the brigade in anappropriate place.

Durante a fase da descolagem o helicpteroembateu numa linha tendo sofrido uma descargaeltrica dos quais resultaram danos ligeiro umadas ps do rotor principal, o para-brisas do ladodireito, uma antena de comunicaes e o ladoesquerdo da fuselagem. O helicptero no tinhacorta cabos instalado.

During the take-off phase of the helicopter hit aline having suffered an electrical discharge whichresulted in slight damage of the main rotorblades, the right side of the windshield, acommunications antenna and the left side of thefuselage. The helicopter had not cut cablesinstalled.

No houve leses nos ocupantes ou terceiros. There were no injuries on the occupants or thirdparties.

No foi emitida nenhuma recomendao desegurana.

No safety recommendations was issued.

1.18.1.4. Incidente 19/INCID/2008 || Incident 23/SUM/2008

Em 12-09-2008, um helicptero Bell 212a operarpara a Helisul estava a participar no combate aum fogo florestal na zona de Castelo Branco.

On 2008, Setember 12th, an helicopter Bell 212operating for Helisul was participating in fightinga forest fire in Castelo Branco zone.


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Depois de efetuar a primeira largada de gua ohelicptero regressava ao ponto dereabastecimento de gua, num rio, descendo aolongo de uma encosta com declive acentuado.

After making the first water drop the helicopterreturned to the water refilling point, in a river,descending along a steeply sloping hillside.

O helicptero embateu com as ps do rotorprincipal numa linha de mdia tenso, nobalizada que atravessava o rio. O pilotoconseguiu controlar o helicptero e regressar base.

The helicopter collided with the main rotorblades in a medium voltage line, not signalled,that crossed the river. The pilot managed tocontrol the helicopter and return to base.

O helicptero sofreu danos nas ps do rotorprincipal e no teto da cabine de pilotagem. Ohelicptero no estava equipado com cortacabos.

The helicopter suffered damage to the mainrotor blades and the ceiling of the cockpit. Thehelicopter was not equipped with cable cutters.

O piloto sofreu escoriaes na regio lombarprovocadas pelos estilhaos da cabine. O pilotono usava capacete.

The pilot suffered bruises in the lower backcaused by shrapnel from the cabin. The pilot wasnot wearing a helmet.

Foram emitidas duas recomendaes desegurana com vista instalao de corta cabosnos helicpteros e utilizao de capacete porparte do piloto.

Two safety recommendations were issued forthe installation of cable cutters and helmetsused by the pilot.

1.18.1.5. Acidente 34/ACID/2009 || Accident 34/ACID/2009

Em 10-09-2009 s 12:45, um helicpteroEurocopter AS350B2 operado pela Helibravoestava a efetuar combate a incndios florestais.

On 2009, September 10tha helicopter EurocopterAS350B2 operated by Helibravo was doing firesfighting in a forest area.

Durante a largada de gua em condies de fracavisibilidade devido ao fumo o piloto noconseguiu evitar umas linhas de mdia tensono sinalizadas que cruzavam por baixo de umasde alta tenso sinalizadas e vista do piloto.

During the water drop in conditions of poorvisibility due to smoke the pilot was unable toavoid a medium voltage unmarked lines crossingbeneath a signalled high voltage one on pilot'ssight.

O helicptero no estava equipado com cortacabos e sofreu danos substanciais nas ps dorotor e patim direito que foi arrancado.

The helicopter was not equipped with cablecutters and suffered substantial damage on mainrotor blades and right skid that was torn.

No houve leses no piloto. The pilot was unarmed.

Foi emitida uma recomendao de seguranacom vista sensibilizao dos tripulantes eoperadores assim como a instalao de cortacabos nas aeronaves envolvidas em combate aincndios.

A safety recommendation for the sensitization ofthe crew and operators was issued as well as theinstallation of cut cables in aircraft involved infire fighting.


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1.18.1.6. Acidente 15/SUM/2009 || Accident 15/SUM/2009

Em 14-10-2009, um helicptero AS350B3operado pela EMA Empresa de Meios Areos

SA, estava a efetuar combate a incndiosflorestais na zona de Penafiel.

On 2009, October 14th an AS350B3 helicopteroperated by EMA - Empresa de Meios Areos SA,

was carrying out a forest fire fighting in Penafielarea.

Durante a manobra de descolagem a partir deum local de enchimento de gua o helicpterofoi arrastado por turbulncia para a direita dasua trajectria inicial tocando com as ps nostrs cabos elctricos que formavam a linha.

During the take-off manoeuvre from a waterfilling spot the helicopter was dragged byturbulence right from its initial course touchingwith the blades in the three electrical cables thatformed a power line.

O helicptero tinha corta cabo instalado e sofreudanos nas ps do rotor principal e no vidro docockpit quebrado por um cabo de electricidade

projectado por efeito de chicote. As linhas foramcortadas.

The helicopter had installed cable cutters andsuffered damage to the main rotor blades andthe cockpit glass broken by a power line by

whiplash effect. The lines were cut.


No foi emitido nenhuma recomendao desegurana.

No safety recommendation was issued.

1.18.1.7. Incidente 12/INCID/2011 || Incident 12/INCID/2011

Em 28-07-2011 s 18:40, um helicpteroAS350B3operado pela EMAEmpresa de MeiosAreos SA, estava a efetuar combate a incndiosflorestais na zona de Valongo.

On 2011, July 28th, at 18:40, one AS350B3helicopter operated by EMA - Empresa de MeiosAreos SA,, was carrying out a fire fighting inValongo zone.

Durante a manobra de descolagem a partir deum local de enchimento de gua o pilotoconseguiu ver nos ltimos instantes uma linha demdia tenso no sinalizada que cruzava o valepor onde descolava.

During take-off maneuver from a water fillingsite the pilot could see in the last moments anon-signalled medium voltage line that crossedthe valley where taking off.

Quando se apercebeu da sua presena, j notinha espao para se desviar lateralmente, nemperformance para passar por cima, pelo queoptou por tentar passar por baixo.

When he realized its presence, had no room todeviate laterally or performance to go over, soopted to try to pass underneath.

Colidiu com 2 dos cabos que formavam a linhaque foram cortados pelo mastro e ps do rotorprincipal.

Collided with two cables that formed the linethat were cut by the mast and main rotor blades.

O helicptero estava equipado com corta cabose sofreu danos menores.

The helicopter had installed cable cutters andsuffered minor damage.



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Foram emitidas duas recomendaes desegurana. Uma com vista reviso dos temposde descanso. Outra alertando para a necessidadede sinalizar os vos mais significativos e maisperigosos.

Two safety recommendations were issued. Onefor the revision of the rest times. Anotherwarning of the need to signal the mostsignificant and most dangerous spans.

1.18.1.8. Resumo das ocorrncias anter iores || Summary of previous

occurences

Um fator comum a todas as ocorrnciasanteriormente descritas a coliso com linhasno sinalizadas. Algumas delas, de acordo com aCIA 10/03, eram consideradas obstculos navegao area deviam estar balizada combolas. Foram emitidas diversas recomendaesde segurana com vista balizagem de linhas demdia tenso.

One factor common to all occurrences describedabove is the collision with unmarked lines. Someof them, according to the CIA 10/03, wereconsidered obstacles to air navigation should bemarked out with signalling balls. Several safetyrecommendations were issued for signallingmedium voltage lines.

Em anos passados no era obrigatrio autilizao de corta cabos em helicpteros queparticipavam em combate a incndios florestais.Atualmente, essa uma obrigao contratual.Noutras modalidades de trabalho areo e emespecial na inspeo de linhas, no h nenhumaobrigao legal nem contratual. Em vrias

ocorrncias foram emitidas recomendaes desegurana com vista instalao de corta cabos.

In past years it was not compulsory the use ofcable cutters in helicopters participating in firefighting fires. Currently, this is a contractualobligation. In other embodiments of aerial workand especially in the inspection lines, there is nolegal or contractual obligation. In severaloccurrences safety recommendations were

issued for the installation of cable cutters.

Tambm foram emitidas vrias recomendaesde segurana no sentido da utilizao decapacete de proteo.

Several safety recommendations to the use ofprotective helmet were also issued.

1.19. Tcnicas de invest igao ut i l izadas || Useful or effect ive

invest igat ion techniques

No foram utilizadas quaisquer tcnicasespeciais de investigao. Todos os estudosforam baseados nos manuais da aeronave eoutros documentos emitidos pelo fabricanteassim como as folhas de planeamento dostrabalhos a realizar pela Labelec.

No special investigative techniques were used.All of the studies were based in aircraft manualsand other documents issued by themanufacturer as well as the planning sheets ofthe work to be undertaken by Labelec.


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2. ANLISE || ANALYSIS

Aps o acidente, a Heliportugal e a Labelectiveram a iniciativa de suspender a operao at

ao esclarecimento das causas e fatores quelevaram sua ocorrncia.

After the accident, Heliportugal and Labelectookthe initiative to suspend operation until

clarification of the causes and factors that led tothis accident.

A Heliportugal e a Labelec fizeram processosindependentes de investigao dos quaisresultaram alteraes aos procedimentos econsequente alterao ao Manual de Operaesde Trabalho Areo da Heliportugal.

Heliportugal and Labelec did independentinvestigation processes which resulted inchanges in the procedures and consequentamendment to Heliportugal Aerial WorkOperations Manual.

2.1.O Helicptero || The hel icopter

2.1.1. Descr io geral || General Descr ipt ion

Este helicptero de cinco lugares aprovadopara operao VFR diurna e noturna e foicertificado para uma tripulao mnima de umpiloto no lugar direito ou um piloto no assentoesquerdo, quando os controles duplosremovveis esto instalados no lado esquerdo.Esta aeronave alimentada por um motor de

turbina. A sua designao comercial :"COLIBRI".

This five seat helicopter is approved for VFR byday and night operation and has beencertificated for a minimum crew of one Pilot inright seat or one Pilot in left seat when theremovable dual controls are installed on the leftside. This aircraft is powered by 1 turbo shaftengine. Its commercial designation is: COLIBRI.

Figura 10 || picture n 10 (Esquema interior || Inside scheme)


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2.1.2. Motor || Engine

O motor transmite a sua fora atravs derotao dos eixos e caixas de desmultiplicao

para o rotor principal e do rotor de cauda.

The engine transmits its power through rotatingshafts and gearboxes to the Main Rotor and the

Tail Rotor.

O motor estava em boas condies mecnicas. Oexame pormenorizado determinou que eleestava a fornecer potncia significativa nomomento do impacto.

The engine was in good mechanical condition.The detailed examination determined that it wasdelivering significant power at the moment ofimpact.

A turbina do gerador de gases e a turbina livrerodavam livre e suavemente.

The gas turbine and the free turbine rotatedfreely and smoothly.

O detetores de partculas magnticas e filtroleo estavam limpos, mostrando que no havia

nenhuma indicao de desgaste anormal.

The magnetic particles detectors and oil filterwere clean indicating that there was no

indication of abnormal wear.

O motor ainda estava ligado estrutura dohelicptero. Os danos foram consistentes com asforas de impacto.

The engine was still attached to the structure ofthe helicopter. The damage were consistent withthe impact forces.

2.1.3. Caixa de transmisso pr incipal || Main Gearbox (MGB)

A caixa de transmisso principal transmite apotncia do motor para a cabea do rotor

principal (MRH), para a caixa do rotor de cauda(TGB) e cabea do rotor de cauda (TRH).

The Main Gearbox transmits the power from theengine to the Main Rotor Head and the Tail

Gearbox (TGB) and Tail Rotor Head (TRH).

Instantes antes de o helicptero atingir as linhaseltricas e, em seguida, o solo, a caixa detransmisso principal ainda estava fornecer apotncia do motor para o rotor principal e psdo rotor de cauda.

Instants before the helicopter hit the power linesand then the ground, the Main Gearbox was stilltransmitting power from the engine to the MainRotor Head and the blades;

A caixa de transmisso principal ainda estavaligada estrutura do helicptero; as quatro

barras de suspenso, segurando a MGB no lugarestavam intactas.

The Main Gearbox was still attached to thehelicopter structure; the four suspension bars,

holding the MGB in place were intact.

2.1.4. Ps do rotor pr incipal || Main rotor blades

Os danos nas ps do rotor so consistentes como impacto com os cabos, o cho e as rvores comuma velocidade de rotao elevada.

The damages on the rotor blades are consistentwith impact with the cables, the ground andtrees at high rotation speed.


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Partes das ps foram encontradas afastadas dolocal principal dos destroos, indicando umaenergia de rotao elevada.

Parts from the blades were found away from themain crash area, indicating also high rotationalenergy.

2.1.5.

Comandos de voo || F l ight controls

O cho da cabine foi esmagado por impacto. Occlico estava dobrado. No foram detetadasfalhas de pr-coliso.

The cabin floor is crushed by impact. The cyclicstick is bent. . No pre-crash failure condition wasseen.

2.2.A carga de trabalho || The workload

Teria sido uma semana normal e um dia normal

para a equipe. A semana comeou com umaviagem de carro com cerca de 3 horas at aoheliporto de Loul. Na tarde de segunda-feira,16, apenas um voo de 02:05 foi realizado.

It would have been a regular week and a regular

day for the team. The week started with a 3hours drive to reach the Loul Heliport. On

Monday 16thonly an afternoon 02:05 flight weremade

Na tera-feira, foram realizados dois voos, um demanh e outro de tarde, num total de 04:05 devoo.

On Tuesday, two flights were made, one in themorning and one in the afternoon, totalling04:05 flight time.

Na quarta-feira, tinha sido realizado um voo pelamanh de 02:20.

On Wednesday, a 02:20 flight was been made inthe morning

O piloto e tcnico, classificaram o trabalho comouma semana calma.

The pilot and the technic classified the work as acalm week.

No foram encontrados indcios de fadiga. No evidence of fatigue was found.

2.3.O pi loto || The pi lot

O piloto tinha experincia limitada no tipo. Nosseus documentos apenas estavam registados

13:55.

The pilot had limited experience on the type.Only 13:55 were recorded in its documents.

No entanto tinha cerca de 200 horas registadasem AS350/EC130. A sua experincia emAS350/EC130 dividia-se em inspeo de linhaseltricas e combate a fogos florestais.

However he had around 200 hours registered inAS350/EC130. His experience in AS350/EC130was divided between power line inspection andfire fighting.

Apesar de serem tipos diferentes, h bastantessemelhanas entre o EC120B e o AS350/EC130.

Although they are different types, there aremany similarities between the EC120B and theAS350/EC130.


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2.4.Heliportugal || Hel iportugal

A inspeo a linhas eltricas uma modalidadede trabalho areo que est devidamente descrita

e aprovada no Manual de Operaes doTrabalho Areo da Heliportugal.

The power lines inspection is an aerial workmodality that is properly described and

approved in the Heliportugal Aerial WorkOperations Manual.

A inspeo de linhas tem um captulo totalmentededicado onde so focados os seguintes temas:alerta para os perigos inerentes ao tipo detrabalho, procedimentos, planeamento do voo,limitaes, treino, operao, tripulao, antes dovoo, depois do voo e responsabilidade pordanos.

The inspection lines have a fully dedicatedchapter where the following topics are focused:alert to the dangers inherent in the type of work,procedures, flight planning, limitations, training,operation, crew, before the flight, after the flightand responsibility for damage.

Em regra, os voos eram agendados por uma

semana.

As a rule, the flights were booked for a week.

Dentro do helicptero, a composio e asposies eram sempre as mesmas (figura n 11).

Inside the helicopter, the composition and thepositions were always the same (picture n 11).


No incio da semana, a equipa fazia um briefing

mais completo que inclua o trabalho emtripulao e medidas de segurana.

Early in the week the team did a fuller briefing

that included team work cooperation andsecurity measures.


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Nos restantes dias o briefing era efetuado demanh, tinha um formato mais reduzido econsistia: em saber qual a zona de trabalho paraverificar se iria voar em espao areo controladoou no controlado; saber qual o tipo de linha(mdia ou alta tenso); determinar qual ocomprimento da linha a ser inspecionada, oprximo ponto de abastecimento, o tempoprevisto para os trabalhos e consequente clculode combustvel.

On the other days the briefing was done in themorning, had a smaller format and consisted in:to know what the work area to see if it would flyin controlled airspace or uncontrolled; knowwhat type of line (medium or high voltage);determine the length of the line to be inspected,the next refuel point, the estimated time for thework and consequent calculation of fuel.

No era efetuado nenhum trabalho programadode levantamento de possveis obstculos ouperigos.

It was not made any scheduled work to identifypossible obstacles or dangers.

Aps o acidente a Heliportugal realizou uma

investigao interna da qual resultou umconjunto de medidas entretanto postas emprtica e descritas em 4.1.

After the accident Heliportugal conducted an

internal investigation which resulted in a set ofmeasures already implemented and described in4.1.

2.5.Labelec || Labelec

A Labelectinha equipas que faziam o trabalho deinspeo de linhas com experincia de vriosanos.

The Labelec had teams that did power lineinspections with several years of experience.

Antes do incio de cada voo realizado, pelaequipa da Labelec, juntamente com o piloto, oplaneamento do voo, com a realizao de umbriefing inicial no qual se discutiam diversosaspetos referentes ao trabalho a realizar e oscuidados a ter, com a identificao dascoordenadas do trabalho a realizar e com aanlise esquema unifilar de linhas.

Before the start of each flight was and is held bythe Labelecteam, along with the pilot, the flightplanning, with the completion of an initialbriefing in which is discussed various aspectsrelated to the work involved and theprecautions, identifying the coordinates of workinvolved and the analysis of the single-linediagram.

A evoluo das inspees era monitorizada combase num esquema como o representado na

figura n 12. Este esquema apenas representavaa linha a ser inspecionada. No havia qualquerreferncia de escala, outras linhas na regio oulinhas a cruzar.

The evolution of inspections was monitoredbased on a scheme like that shown in picture n

12. This scheme only represented the line to beinspected. There was no reference scale, otherlines in the region or crossing lines.


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O termografista tinha pouca possibilidade de

ajudar na deteo de obstculos. Por um lado iasentado atrs e por outro tinha que operar osequipamentos de inspeo.

The thermographer had little chance of helping

the obstacle detection. On the one hand wassitting behind and the other had to operateinspection equipment.

O observador tinha a misso efetuar a inspeovisual de linhas eltricas com vista deteo dedefeitos e definio das linhas a inspecionar.Isso fazia-o ter que verificar o esquema a bordoe por conseguinte ter que olhar para dentro. Oesquema no tinha qualquer referncia a outraslinhas tal como indicado na figura n 13. O

observador devia, tambm, sempre que tal seafigurasse possvel, ajudar o piloto na deteo deobstculos.

The observer mission was to make a visualinspection of power lines for the detection ofdefects and the definition of the lines to inspect.This made him have to check the schedule onboard and therefore have to look inside. Thescheme had no reference to other lines as shownin picture n 13. The observer should also,

whenever this was possible, help the pilot inobstacle detection.

A misso primria do piloto era voar ohelicptero em segurana, nomeadamentedetetando obstculos, no devendo fazer opapel de observador.

The pilot's primary mission was to fly thehelicopter safely, including detecting obstaclesand should not do the role of observer.


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2.6.L inhas eltr icas || Powerl ines

As linhas eltricas so fatais. Power lines are fatal.

sabido que as linhas eltricas so um perigopara a aviao. A visibilidade de uma linhadepende principalmente das condies de luz edo contraste. Por norma fcil um observadorterrestre detetar uma linha j que esta sedestaca no cu. O contrrio aplica-se a umobservador areo. Normalmente os cabos queconstituem as linhas brilham do lado onde incidea luz solar e esto escuros do outro. Quando

observados a partir do lado escuro so muitodifceis de identificar se projetados num fundoque no cause contraste.

It is known that the electrical lines are a hazardto aviation. The visibility of a line depends mainlyon the light and the contrast conditions. Usuallyit is easy to a terrestrial observer detect a line asthis stands out in the sky. The opposite applies toan aerial observer. Usually the cables are linesshine on the side towards the sunlight and aredarker than the other side. When observed fromthe "dark" side they are very difficult to identify

if they have a background that that does notcause contrast.

A figura n 14, fotografada do solo a nordeste dolocal do acidente, mostra a linha embatida aatravessar o vale e a contrastar pouco numfundo constitudo por rvores.

The picture n 14, taken from ground northeastof the accident site, shows the accident linecrossing the valley and the little contrast in abackground made up of trees.

A linha era formada por conjunto de 3 caboscom uma rea de 160 mm2, correspondendo a

um dimetro de 7,14 mm.

The power line was made by a set of three cableswith 160 mm2 of area, corresponding to a

diameter of 7,14 mm.

Linha a inspecionarInspecting line

Linha que cruza (no est no esquema original)Crossing line (not on original plotting)


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Figura 14 || picture n 14

Por ser difcil a deteo de linhas distncia os

pilotos procuram constantemente identificar ospostes que em regra so visveis a maioresdistncias. Quando a voar em vales com linhas acruzar, por vezes os postes destacam-se nascristas, contrastando com o cu, acima da linhade horizonte. Neste caso os postes ficavamnuma cota inferior s cristas, dentro do vale,

tornando a sua identificao mais difcil.

Because it is difficult to detect lines from

distance pilots constantly seek to identify theposts that usually are visible at greater distances.When flying in valleys with crossing lines,sometimes the posts stand out on the crests, incontrast with the sky above the horizon line. Inthis case the posts were in a lower level to thecrests, "inside" the valley, making identificationmore difficult.

As linhas eltricas so mantidas de forma aterem um limite de segurana que deve estar

limpo de rvores e vegetao. No dia doacidente estavam a decorrer trabalhos dedesmatao e limpeza nessa rea de segurana.Os postes encontravam-se parcialmente ocultoscom vegetao dificultando a sua observao emvoos a baixa altitude.

The electrical lines are maintained in order tohave a security area that must be cleared of

trees and vegetation. On the day of the accidenton going work of deforestation and cleaning ofthe security area was in progress. The poles werepartially hidden with vegetation hindering itsobservation at a low altitude flight.

A CIA 10/03 de 06 de maio Limitaes em alturae balizagem de obstculos artificiais navegaoarea estabelece regras a adotar para

caracterizar e balizar obstculos areos.

The Aeronautical Information Circular (CIA)10/03 of May 06th Limitations in height andbeacon of artificial obstacles to air navigationdowns the rules to be adopted to characterizeand delimit overhead obstacles.


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Refere a CIA em 3.1.f. que uma linha eltricadeve ser considerado obstculo quando Estejaassociada ao vo de uma linha area cujosapoios distem mais de 500 metros entre si;. Nocaso concreto, o vo do local do acidente tinha485 metros

Paragraph 3.1.f. of that CIA refers a power linemust be considered an obstacle when Beassociated with the span of an airline whosepoles are more than 500 meters apart;" The spanof the accident site had 485 meters.

Refere a mesma CIA em 3.1.g. que deve aindaser considerado obstculo quando Correspondaa qualquer ponto de uma linha area que cruzevales ou cursos de gua que exceda a altura de60 metros em relao s cotas da sua projeohorizontal sobre o terreno....

The same CIA in 3.1.g. refers that must beconsidered an obstacle when any point of anairline that crosses valleys or watercourses thatexceeds the height of 60 meters in relation tothe height of its horizontal projection on theground ...".

As regras para a balizagem tambm estodefinidas na mesma CIA e incluem o recurso a

bolas de balizagem de cor branca, laranja evermelha, variando o seu espaamento com asua dimenso.

The rules for the signalling are also defined in thesame CIA and include the use of white, orange

and red signalling balls, varying their spacing toits size.

Esta comisso alerta para o facto de, noobstante a balizagem no ser obrigatria nestecaso, bem como os demais mencionados nesterelatrio (que foram escolhidos por teremcaractersticas similares), terem ocorrido emlinhas no balizadas.

This committee alert to the fact that, despite thesignalling is not mandatory in this case as well asothers mentioned in this report (which werechosen because they have similar characteristics)have occurred in non-signalized lines.

O Manual VFR publicado e promulgado pelosServios de

Power Line Colision- Eurocopter EC120B Colibri

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