The findings are detailed in the final report from the Office for the Prevention and Investigation of Aeronautical and Railway Accidents (GPIAAF), concerning the helicopter accident that occurred on August 30 in Cambres, Lamego, Viseu district, resulting in the deaths of five members of the GNR Emergency Protection and Relief Unit (UEPS).
“This accident, alongside the regulatory environment of aerial firefighting activities and the number of safety incidents resulting in fatalities recorded annually, highlights the need and opportunity for an urgent review of Regulation No. 641/2022,” the GPIAAF underscores.
Due to the identification of gaps in the training details of pilots involved in firefighting, which could have been crucial in preventing the accident, the investigation reiterated a recommendation to the National Civil Aviation Authority (ANAC), the sector regulator, made in July 2023.
The GPIAAF recommends that ANAC “adjust and detail the training requirements for pilots involved in firefighting activities, specifically in the general and transversal principles of human factors.”
The investigation suggests that this review should not be limited to aspects such as “loss of situational awareness, tunnel vision, over-motivation, management of external pressures, and Crew Resource Management [CRM] concepts to ensure it results in an acceptable level of operational safety performance.”
“As extensively debated in investigation reports of similar events, the implementation and validation of crew training requirements, particularly in human factors, must be urgently reviewed,” the GPIAAF warns.
This body stresses that “it is necessary to monitor and evaluate the practical implementation of the requirements, the difficulties of operators, and the supervision of the type, detail, and effectiveness of the training provided to pilots by operators.”
In 2015, the GPIAAF issued a safety recommendation to ANAC that “crews involved in water operations, namely helicopter and amphibious airplane pilots, should start wearing life vests.”
A decade later, “this recommendation remains without a useful response” from the national regulator.
Regarding the normalization of route deviations, general acceptance among involved parties, and lack of supervision by various entities, factors considered contributory to the accident, the report states that the Air Force has taken steps to supervise flights, declaring that “in the face of such deviations and in case of doubt,” through the Mission Coordination Office within the scope of Rural Fire Incidents, “it will request additional information from the respective operators.”
The GPIAAF also issued three safety recommendations to the operator of the crashed helicopter: “to reassess the safety management system to implement a system for collecting and processing flight data, addressing identified deviations; to conduct a risk analysis of the operation and determine the minimum safety equipment on board,” and to “establish a detailed training program in aspects of human factors and CRM management for its operatives.”
In the same domain of human factors, there is also a recommendation to GNR/UEPS to establish a training program for its operatives in collaboration with operators and ANAC, “adapting the concept of mission specialists as envisaged by EASA,” the European aviation sector regulator.
