PP-MCJ 05 06 2022-Pub - Ing.

COMANDO DA AERONÁUTICA
CENTRO DE INVESTIGAÇÃO E PREVENÇÃO DE

ACIDENTES AERONÁUTICOS
FINAL REPORT
A-069/CENIPA/2022
OCCURRENCE: ACCIDENT
AIRCRAFT: PP-MCJ
MODEL: 206B
DATE: 05JUN2022
FORMRFE 0223
A-069/CENIPA/2022 PP-MCJ 05JUN2022
NOTICE
According to the Law nº 7565, dated 19 December 1986, the Aeronautical Accident
Investigation and Prevention System – SIPAER – is responsible for the planning, guidance,
coordination, and execution of the activities of investigation and prevention of aeronautical
accidents.
The elaboration of this Final Report was conducted considering the contributing factors and
hypotheses raised. The report is, therefore, a technical document which reflects the result obtained
by SIPAER regarding the circumstances that contributed or may have contributed to triggering this
occurrence.
The document does not focus on quantifying the degree of contribution of the distinct factors,
including the individual, psychosocial or organizational variables that conditioned the human
performance and interacted to create a scenario favorable to the accident.
The exclusive objective of this work is to recommend the study and the adoption of provisions
of preventative nature, and the decision as to whether they should be applied belongs to the President,
Director, Chief or the one corresponding to the highest level in the hierarchy of the organization to
which they are being forwarded.
This Final Report has been made available to the ANAC and the DECEA so that the
technical-scientific analyses of this investigation can be used as a source of data and information,
aiming at identifying hazards and assessing risks, as set forth in the Brazilian Program for Civil
Aviation Operational Safety (PSO-BR).
This Report does not resort to any proof production procedure for the determination of civil
or criminal liability, and is in accordance with Appendix 2, Annex 13 to the 1944 Chicago
Convention, which was incorporated in the Brazilian legal system by virtue of the Decree nº 21713,
dated 27 August 1946.
Thus, it is worth highlighting the importance of protecting the persons who provide
information regarding an aeronautical accident. The utilization of this report for punitive purposes
maculates the principle of “non-self-incrimination” derived from the “right to remain silent”
sheltered by the Federal Constitution.
Consequently, the use of this report for any purpose other than that of preventing future
accidents, may induce to erroneous interpretations and conclusions.
N.B.: This English version of the report has been written and published by the CENIPA with the
intention of making it easier to be read by English speaking people. Considering the nuances of
a foreign language, no matter how accurate this translation may be, readers are advised that
the original Portuguese version is the work of reference.
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SYNOPSIS
This is the Final Report of the 05 June 2022 accident with the model 206B aircraft,
registration marks PP-MCJ. The occurrence was typified as “[LALT] Low Altitude Operation”.
During a flight for the inspection of electrical transmission lines, the aircraft collided
with a transmission line cable and fell into a dam.
The aircraft was destroyed.
The three crewmembers suffered fatal injuries.
Being the United States of America the State of design/manufacture of the aircraft, the
USA’s NTSB (National Transportation Safety Board) designated an accredited
representative for participation in the investigation of the accident.
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TABLE OF CONTENTS
1.1. History of the flight. ........................................................................................................ 7

1.2. Injuries to persons. ........................................................................................................ 7
1.3. Damage to the aircraft. .................................................................................................. 7
1.4. Other damage................................................................................................................ 8
1.5. Personnel information.................................................................................................... 8
1.5.1. Crew’s flight experience. .......................................................................................... 8
1.5.2. Personnel training. ................................................................................................... 8
1.5.3. Category of licenses and validity of certificates. ....................................................... 8
1.5.4. Qualification and flight experience. ........................................................................... 8
1.5.5. Validity of medical certificate. ................................................................................... 9
1.6. Aircraft information. ....................................................................................................... 9
1.7. Meteorological information. ......................................................................................... 10
1.8. Aids to navigation. ....................................................................................................... 13
1.9. Communications. ......................................................................................................... 14
1.10. Aerodrome information. ............................................................................................. 14
1.11. Flight recorders. ........................................................................................................ 14
1.12. Wreckage and impact information. ............................................................................ 14
1.13. Medical and pathological information. ....................................................................... 23
1.13.1.Medical aspects. ................................................................................................... 23
1.13.2.Ergonomic information. ......................................................................................... 24
1.13.3.Psychological aspects. ......................................................................................... 25
1.14. Fire. ........................................................................................................................... 25
1.15. Survival aspects. ....................................................................................................... 25
1.16. Tests and research. ................................................................................................... 25
1.17. Organizational and management information. ........................................................... 26
1.18. Operational information. ............................................................................................ 31
1.19. Additional information. ............................................................................................... 33
1.20. Useful or effective investigation techniques............................................................... 39
3.1. Findings. ...................................................................................................................... 42

3.2. Contributing factors. .................................................................................................... 43
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GLOSSARY OF TECHNICAL TERMS AND ABBREVIATIONS

ABNT Brazilian Association of Technical Standards
AGL Above Ground Level
ALA Asociación Latinoamericana de Aeronáutica
ANAC Brazil’s National Civil Aviation Agency
ANEEL Brazilian Electricity Regulatory Agency
BKN Broken clouds (5 - 7 oktas of the sky)
CB Cumulonimbus cloud
CENIPA Brazil’s Aeronautical Accidents Investigation and Prevention Center
CHESF São Francisco’s Hydroelectric Company (Brazil)
CIV Pilot Logbook
CMA Aeronautical Medical Certificate
CPTEC Center for Weather Forecasting and Climate Studies (Brazil)
CRM Crew Resource Management
CU Cumulus cloud
DECEA Department of Airspace Control (Brazil)
CVA Airworthiness-Verification Certificate
DOSPA Paulo Afonso’s Aviation Division
EASA European Union Aviation Safety Agency
ELT Emergency Locator Transmitter
FEW Few clouds (1 - 2 oktas of the sky)
FIR Flight Information Region
GAMET General Aviation Meteorological Information
GPS Global Positioning System
HMNT Single-Engine Turbine-Helicopter Class Rating
hPa Hectopascal
ICA Command of Aeronautics’ Instruction
INMET National Institute of Meteorology (Brazil)
IS Supplementary Instruction
LABDATA Cenipa’s Laboratory for Readout and Analysis of Flight Recorder Data
LALT Low Altitude Operation
LT Transmission Line
METAR Routine Meteorological Aerodrome Report
NM Nautical Miles
NSCA Command of Aeronautics’ System Norm
NTSB National Transportation Safety Board (USA)
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OM Maintenance Organization
PSAC Civil Aviation Service Provider
PCH Commercial Pilot License - Helicopter
PIC Pilot in Command
PMD Abbreviation in Portuguese for Maximum Takeoff Weight
PN Part Number
PPH Private Pilot License - Helicopter
RBAC Brazilian Civil Aviation Regulation
REDEMET Command of Aeronautics’ Meteorology Network (Brazil)
RMK Remarks
SACI Civil Aviation Integrated Information System
SBMS ICAO location designator - Dix-Sept Rosado Aerodrome, Mossoró,
State of Rio Grande do Norte, Brazil)
SAE Specialized Public Air Service Aircraft Registration Category
SBSG ICAO location designator - São Gonçalo do Amarante Aerodrome
(Gov. Aluízio Alves), Natal, State of Rio Grande do Norte, Brazil
SC Stratocumulus cloud
SCT Scattered clouds (3 - 4 oktas of the sky)
SGSO Safety Management System
SIGWX Significant Weather Chart
SIPAER Aeronautical Accidents Investigation and Prevention System
SN Serial Number
SPECI Aviation Selected Special Weather Report
TAESA Aliança Electric-Energy Transmission Corporation
TCU Towering Cumulus cloud
TPP Private Air Service Aircraft Registration Category
UTC Coordinated Universal Time
VCSH Showers in the vicinity
VFR Visual Flight Rules
WAC World Aeronautical Chart
WSPS Wire Strike Protection System
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1. FACTUAL INFORMATION.
Model: 206B Operator:
Aircraft Registration: PP-MCJ Companhia Hidro Elétrica do São
Manufacturer: Bell Helicopter Francisco
Date/time: 05JUN2022 – 16:36 UTC Type(s):
Location: Sítio Tamanduá - Alto do [LALT] Low altitude operations
Caboclo
Occurrence
Lat. 06°13’07”S Long. 036°32’34”W
Municipality – State: Currais Novos –
Rio Grande do Norte
1.1. History of the flight.
At 15:34 UTC, the aircraft took off from SBSG (São Gonçalo do Amarante Aerodrome
- Governador Aluízio Alves - Natal, State of Rio Grande do Norte) destined for SBMS (Dix-
Sept Rosado Aerodrome, Mossoró, Rio Grande do Norte) on a flight for inspection of the
CHESF (São Francisco Hydroelectric Plant) 138-kV transmission line, with three POB
(crew).
During the flight, the aircraft collided with a transmission line of TAESA (Transmissora
Aliança de Energia Elétrica S.A) near the town of Currais Novos. Subsequently, the aircraft
fell into a dam and sank (partially).
Figure 1 – View of the PP-MCJ at the accident site.

The three crewmembers of the aircraft suffered fatal injuries.
1.2. Injuries to persons.
Injuries Crew Passengers Others
Fatal 3 - -
Serious - - -
Minor - - -
None - - -
1.3. Damage to the aircraft.
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1.4. Other damage.

The lightning-rod cable of TAESA's 230-kV transmission line broke, and fuel from the
aircraft dispersed into the reservoir.
1.5. Personnel information.
1.5.1. Crew’s flight experience.
FLIGHT EXPERIENCE
PIC
Total Unknown
Total in the last 30 days 12:05
Total in the last 24 hours 03:50
In this type of aircraft Unknown
In this type in the last 30 days 12:05
In this type in the last 24 hours 03:50
N.B.: according to the records of Integrated Civil Aviation Information System (SACI),
the Pilot in Command (PIC) had 336 hours and 38 minutes of total flight time, and 277 hours
and 37 minutes on the model of the accident aircraft.
The Investigation Committee did not have access to the PIC's CIV (Pilot Logbook).
According to third-party accounts, the PIC had more than 3,300 flight hours.
1.5.2. Personnel training.
The PIC did his PPH course (Private Pilot – Helicopter) in 1981, at the Aeroclube de
Nova Iguaçu, State of Rio de Janeiro.
1.5.3. Category of licenses and validity of certificates.
The PIC held a PCH License (Commercial Pilot - Helicopter), and a valid HMNT rating
(Single Engine Turbine Helicopter Class.
1.5.4. Qualification and flight experience.
Digital CIV records indicated that the PIC had been operating the B-206B aircraft,
registration PP-MCJ, since June 2012, carrying out LT inspection flights in the Northeast
region of the country.
Part of the PIC's operational background developed when he started working for the
operator in November 1987. In that period, according to data contained in SACI, he flew the
following aircraft models: Bell 205, 206, and 212.
The last flight logged in the PIC’s digital CIV dated from 04 November 2021.
Notwithstanding, the Investigation Committee considered that the pilot met the criteria
established in Section 21, Amendment nº 13, Subpart A, of the Brazilian Civil Aviation
Regulation nº 61 (RBAC-61) , referring to recent experience, due to flights conducted in the
previous ninety days, but not recorded in the logbook.
The PIC was qualified for and had experience in the type of flight.
The two inspectors had experience in inspecting LTs from the ground.
In the second half of 2020, they performed the first aerial inspections. By the date of
the accident, one of the inspectors had flown approximately 21 hours dedicated to aerial
inspection of LTs, having inspected the segment where the accident occurred on four
occasions. Similarly, the other inspector had performed 8 hours of flight time in aerial
inspections of LTs, having once inspected, on another flight, the segment in which the
accident occurred.
None of the inspectors had flown with the PIC before.
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1.5.5. Validity of medical certificate.

The PIC held a valid CMA (Aeronautical Medical Certificate).
1.6. Aircraft information.
The SN 4555 model 206B aircraft was a product manufactured by Bell Helicopter in
2001, and registered in the TPP category (Private Air Services).
The helicopter's PMD (Maximum Takeoff Weight) established by the manufacturer,
was 1,519 kg, and the minimum crew was one pilot.
The CVA (Airworthiness-Verification Certificate) of the aircraft was valid.
The records of the airframe and engine logbooks were up to date.
The Claro Comércio, Representações e Manutenção Aeronáuticas Ltda. Maintenance
Organization (municipality of Paulo Afonso, State of Bahia) carried out the last (“weekly”
type) inspection of the aircraft on 30 May 2022. The aircraft flew 12 hours and 5 minutes
after the referred inspection.
The last “100-hour” type inspection of the aircraft was carried out by the same
maintenance organization mentioned above on 10 March 2022. The aircraft flew 34 hours
and 25 minutes after the said inspection.
One found no evidence of failures or malfunctions of the aircraft or its components that
might have contributed to the occurrence.
The aircraft had a Wire-Strike Protection System, consisting of an upper and a lower
wire-cutting device. Its windshield had a deflector along its middle section (Figure 2).
Figure 2 - View of the PP-MCJ aircraft. Source: Jetphotos.net
Figure 3 shows a detailed view of the upper wire-cutter.
Figure 3 - Detailed view of an upper wire-cutter.
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1.7. Meteorological information.

The Investigation Committee had access to messages exchanged between the PIC
and members of his working group. Such messages contained information on the
meteorological conditions that would affect the inspection flights scheduled for the week of
the accident.
The presence of adverse weather conditions during the period of operations had
already caused the cancellation of the initial flight of the aforementioned schedule, causing
the aircraft to return to the municipality of Paulo Afonso on the morning of 31 May 2022.
The Investigation Committee used information and products available on
meteorological websites for the analysis of the weather conditions on the day of the accident.
The websites consulted were REDEMET (Command of Aeronautics’ Meteorology Network);
CPTEC (Center for Weather Forecasting and Climate Studies); INMET (National Institute of
Meteorology); and GEOAISWEB (a free software system, which made aeronautical
information available directly on a map, enabling its integrated use with Aeronautical
Charts).
The 18:00 UTC SIGWX of 05 June 2022 (with information from the surface up to
FL250, and valid from 15:00 UTC to 21:00 UTC) had the following forecast: broken cumulus
and stratocumulus clouds (base at 1,700 ft and top at 6,000 ft), towering cumulus clouds
(base at 2,500 ft and top at 24,000 ft), and rain showers in the area of interest (Figure 4).
Figure 4 - SIGWX chart (from surface to FL 250). Source: REDEMET.
The 05 June 2022 GAMET of FIR-RE (Recife Flight Information Region), valid from
12:00 UTC to 18:00 UTC, forecast the following weather conditions for the region:
- surface visibility of 3,000 m due to rain;
- isolated thunderstorms;
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- isolated CB clouds (base at 3,000 ft and top above FL100);

- isolated TCU clouds (base at 2,500 ft and top above FL100);
- significant cloudiness at low altitudes (base at 800 ft. and top 1,400 ft, from 5 to 7
oktas (BKN); and
- cumulus-type cloudiness at low altitudes (base at 1,700 ft. and a top at 6,000 ft,
from 3 to 4 oktas (SCT).
The SBSG 15:00 UTC METAR of 05 June 2022 contained information of wind from
250° at 4 kt, varying between 220° and 290°, visibility 9,000 m , rain in the vicinity, BKN at
1,500 ft, FEW towering cumulus clouds at 2,000 ft, BKN at 4,000 ft, temperature 25°C, dew
point 24°C, and atmospheric pressure 1,014 Hectopascal.
METAR SBSG 051500Z 25004KT 220V290 9000 VCSH BKN015 FEW020TCU
BKN040 25/24 Q1014=
In turn, the SBSG 15:17 UTC SPECI of 05 June 2022 had information of wind from
220° at 6 kt, varying between 130° and 250°, visibility of 9,000 m, rain in the vicinity, BKN at
9,000 ft, FEW towering cumulus clouds at 2,000 ft, BKN at 10,000 ft, temperature 25°C, dew
point 23°C, and atmospheric pressure of 1,013 Hectopascal.
SPECI SBSG 22006KT 130V250 9000 VCSH BKN009 FEW020TCU BKN100 25/23
Q1013=
The 05 June 2022 15:00 UTC METAR of SBMS (destination aerodrome), had
information of wind from 170° at 7 kt, visibility more than 10 km, BKN at 2,000 ft, scattered
clouds at 9,000 ft, temperature 32°C, dew point 23°C, and atmospheric pressure of 1.013
Hectopascal.
SBMS 051500Z 17007KT 9999 BKN020 SCT090 32/23 Q1013=
Figure 5, extracted from the REDEMET, shows the Visible Satellite Image of the region
of interest on 05 June 2022 at 16:40 UTC, close to the time of the accident.
Figure 5 - Satellite Image of the region where the accident occurred.
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The records of daily precipitation measured in meteorological data contained in the

map of INMET meteorological stations showed a volume of 43.3 mm for the locality of Caicó,
State of Rio Grande do Norte, located at a distance of approximately 46.5 NM away from
the accident site.
Figure 6 - Daily precipitation in millimeters on 05 June 2022. The arrow indicates the
approximate trajectory of the aircraft. Source: INMET.
According to reports made by observers in the town of Currais Novos, located

approximately 4 km away from the accident site, it was raining in the area.
A video, recorded moments before the accident, shows the helicopter in flight moments
before the accident under the limited visibility conditions present in that region (Figure 7).
Figure 7 - Image of the PP-MCJ flying over the locality of Currais Novos.
Thus, given the meteorological conditions observed and forecast for the accident
region, the Investigation Committee verified the existence of a relatively unstable
atmospheric condition that featured rainy weather, with restricted visibility and variable
cloudiness spread in various layers.
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Therefore, one inferred that there were significant active meteorological phenomena,
such as TCU clouds, rain showers, and low stratiform clouds over the region where the
accident occurred.
1.8. Aids to navigation.
The aircraft operator had a WAC (World Aeronautical Chart), scale 1:1,000,000, issued
by the Institute of Aeronautical Cartography (ICA), as well as a tablet and GPS
navigation/positioning equipment, containing the delimitations of the transmission lines
selected for inspection.
Next to the wreckage, one found the chart WAC 3018, 4th edition, from July 2004, in
which the CHESF LTs were marked for purposes of flight planning. The Investigation
Committee found, however, that the WAC was out of date and did not contain the mapping
of the 230-kV LT that crossed with the 138-kV LT chosen for inspection.
Additionally, one verified that the chart did not have the other LT intersections marked
in the planning of flights (Figure 8).
Figure 8 – Chart WAC 3018 - 4th Edition, 2004, found at the accident site.
At the time of the accident, the Chart WAC 3018, sixth edition, was the one in force
(since 05 November 2020), with topographic data updated as of April 2020. In this
publication, the 230-kV LT and its respective intersection with the 138-kV LT were mapped
(Figure 9).
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Figure 9 – Chart WAC 3018 - 6th Edition, 2020, in force on the date of the accident.
1.9. Communications.
NIL.
1.10. Aerodrome information.
The occurrence was outside aerodrome area.
1.11. Flight recorders.
Installation of recorders on the aircraft was not required.
The portable Garmim Aer 760GPS equipment used by the PIC at the time of the
accident was sent to the Cenipa’s LABDATA (Laboratory for the Readout and Analysis of
Flight Recorder Data) for the reading of the memory card. However, extraction of data was
not possible due to the degree of damage sustained by the referred equipment.
1.12. Wreckage and impact information.
The aircraft was equipped with an ELT (Emergency Locator Transmitter), PN 2619502-
0027 and SN S1840501-01, with annual inspection valid until 10 March 2023. The ELT
battery (PN LX1100457880, SN S1840510-01) was valid until 01 March 2023.
There were no records of the ELT’s activation after the impact.
The PP-MCJ was flying parallel to the CHESF’s 138-kV LT at a height of approximately
30 m, when it encountered the oblique intersection with the TAESA’s 230-kV LT against
which it collided.
Figures 10 and 11 show the intersection of the 138-kV LT with the 230-kV LT in the
region close to the accident site.
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Figure 10 - Top view of the intersection of the 138-kV LT with the 230- kV LT.
In highlight, the dam where the PP-MCJ was found. Source: CHESF.
While the 138-kV LT had an average height of 30 m, and its electric cables were
separated horizontally, the 230-kV LT cables had a height of approximately 40 m. (Figure
11).
Figure 11 - Intersection of the 138-kV LT with the 230-kV LT.
The helicopter collided with a lightning-rod cable in the upper part of the 230-kV LT at
a height of 41.66 meters. The transmission line cables were arranged vertically, as shown
in the illustrative image in Figures 12 and 13.
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Figure 12 - Vertical arrangement of LT cables.
Figure 13 - Illustrative image of lightning-rod cables on the top of a LT.
The aircraft fell into a dam, at a distance of approximately 30 m from the point of
collision, as shown in Figure 14.
Figure 14 – Croquis of the accident.
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Figure 15 shows an overview of the distances in the region where the accident
occurred, illustrating the location of the helicopter collision against the 230-kV LT, and the
respective elevations in relation to sea level.
Figure 15 – Croquis with the dimensions of the LT and terrain elevations.
The wreckage was relatively concentrated, and was found partially submerged in the
dam, and with the intermediate segment of the lightning rod attached to the aircraft (Figure
16).
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Figure 16 - Aspect of the partially submerged wreckage.
One found a broken segment of the lightning rod entangled in the main rotor (Figure
17).
Figure 17 – Lightning-rod cable segment broken in two places (highlighted ends).
The main rotor blades showed damage and marks compatible with contact with the
lightning-rod cable (Figure 18).
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Figure 18 – Contact marks (grooves) between the lightning-rod cable

and the leading edge of one of the main rotor blades.
Figure 19 shows the two blades of the main rotor, with the lightning-rod cable wrapped
close to the root of one of them.
Figure 19 - View of the two main rotor blades.
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The main rotor mast was sectioned near the main rotor hub, and showed signs of
rubbing against the lightning-rod cable (Figure 20).
Figure 20 - Upper segment of the sectioned main-rotor mast (A) and

detail of the rubbing marks against the lightning-rod cable (B).
Figures 21 and 22 show that the lower wire-cutter device had no traces of contact with
the cable.
Figure 21 - Detail of the aircraft's lower wire-cutter with no traces

of contact with the lightning-rod cable.
Figure 22 - Enlarged image of the aircraft's lower wire-cutter.
The helicopter's upper wire-cutter showed evidence of contact with the LT lightning-
rod cable (Figure 23).
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Figure 23 - Upper wire-cutter with evidence of contact with the lightning-rod cable.
The central deflector on the aircraft's windshield did not show any marks of contact
with the lightning-rod cable (Figure 24).
Figure 24 - General view of the upper wire-cutter with the

central deflector of the windshield.
The rear part of the central structure, as well as the attachment rods of the upper wire-
cutter, showed signs of contact with the lightning-rod cable (Figure 25).
Figure 25 - General condition of the upper wire-cutter.
The left side of the rear skid cross tube showed signs of friction with the lightning-rod
cable (Figure 26).
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Figure 26 – Lightning-rod cable markings on the rear cross tube.
There was substantial damage to the left-hand horizontal stabilizer, with sectioning of
the tail cone and tail rotor transmission shaft (Figure 27).
Figure 27 - Damage to the left-hand horizontal stabilizer, with sectioning

of the tail boom and tail-rotor transmission shaft.
Figure 28 shows the damage to the tail rotor and the separation of the transmission
box.
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Figure 28 - View of the tail rotor and transmission box.
The aircraft's fuel tank sustained rupture (Figure 29).
Figure 29 – Aircraft debris, with the fuel tank in highlight.
1.13. Medical and pathological information.

1.13.1. Medical aspects.
According to reports, the PIC had no history of health problems.
With regard to the PIC's working hours, no aspects were identified in conflict with those
described in the RBAC-117 - “Requirements for Human Fatigue Risk Management”,
Amendment No. 00, dated 13 March 2019.
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From the results of the exams and analyses carried out, the investigation did not detect
any substances with a mass spectrum compatible with drugs of abuse and/or
pharmaceuticals.
There was no evidence that issues of physiological nature might have affected the
pilot's performance.
1.13.2. Ergonomic information.
On 20 November 2017, Flight Safety Australia published the article “Wire, the Invisible
Enemy”.1
Based on an interview with expert Robert A. Feerst, the article highlights that wires
may disappear from the eyes and become invisible. Even for a trained crew, several factors
make wires invisible much of the time.
According to him, such factors include: atmospheric conditions; cockpit ergonomics;
dirt or scratches on cockpit windows; viewing angle; sun position; visual illusions; pilot's
scanning abilities and visual acuity; cockpit workload; and camouflaging effect of nearby
vegetation.
A photo published on the Piloto Policial website corroborates the article, showing the
effect of rain droplets on the windshield of a helicopter (Figure 30).
Figure 30 - Influence of rain droplets on the windshield of a helicopter,

compromising the pilot's visibility. Source: Piloto Policial website.
The article also warns that older wires may be difficult to see due to color changes over
time. Copper wires, for example, oxidize and acquire a greenish color that makes them
camouflaged amid vegetation.
A wire that is perfectly visible from one direction may become invisible from the
opposite. The exact location of specific wires may change throughout the day because of
fluctuating ambient temperatures, which may cause wires to sag or tighten.
Even on a cloudless day, the blue of the sky can change to reveal, or hide, wires.
1
Available on: https://www.flightsafetyaustralia.com/2017/11/wire-the-invisible-enemy/.
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Long spans of wire lines may be blown by the wind, with displacements of tens of
meters for wires crossing valleys.
Additionally, there are two types of illusions related to transmission lines, which
deserve special attention:
- High-wire illusion: for two parallel wires at a distance of 200 m or more, the higher
wire will appear further away, when it may not be; and
- Phantom-line illusion: a wire running parallel to others can become camouflaged.
According to Feerst, there are some principles one has to understand in the wire
environment, and if one does not, one is operating on luck. “In environments where there
are wires, it doesn't matter if you have 100 hours or 10,000 hours.” This being said, he lists
three deadly assumptions:
That you will see the wire in time. You can never count on it. It's a mentality you need
to get out of your head.
Never assume you and the pilot are seeing the same thing. Never assume the pilot
has seen the wire.
Never assume airspace is protected by marking and lighting. You just cannot count
on that.
The article ends by concluding that:
[...] if you do not have to fly in a wire environment, do not go there. If you do have to,
seek training and regular retraining. Wire is an enemy that must be taken seriously.
1.13.3. Psychological aspects.
According to information provided by a family member, the PIC was a calm-tempered
person, who was responsible and very diligent in relation to his work.
His relationship with his workmates and family members was reported to be
harmonious with everyone.
His professional experience started in a company dealing with operations connected
to offshore oil-and-gas exploration. Later, he joined CHESF, where he worked for around 33
years.
According to reports, in the two months preceding the accident, the pilot appeared to
be well. However, he would show a certain level of irritation with some work issues, although
he did not display any emotional alterations or changes in his behavioral patterns that might
compromise the performance of his function.
Still according to reports, the PIC did not make use of controlled medications and, on
the day of the accident, there were no records of any events outside the daily routine or
even family-related problems.
It is worth noting that, by telephone, the PIC commented on the unfavorable weather
conditions for the flight that resulted in the accident.
1.14. Fire.
There was no fire.
1.15. Survival aspects.
There were no survivors.
1.16. Tests and research.
With the aim of calculating the speed of the PP-MCJ from a video recorded by an
observer, the Investigation Committee measured the aircraft's displacement in relation to its
length (9.50 m) in the interval of five consecutive frames.
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Figure 31 - Measurement of displacement (9.24 m) calculated

in comparison with the length of the aircraft (9.50 m).
Considering the interval of five frames for the video, at a rate of 20 frames per second,
one determined that the aircraft was moving 9.24 m in 5/20 s.
Therefore, the estimated aircraft speed recorded on video during the flight near the
urban perimeter of Currais Novos was 71.84 kt (36.96 m/s).
1.17. Organizational and management information.
The PP-MCJ was an aircraft operated by CHESF, whose main activity was the
generation, transmission, and sale of electrical energy. The company provided energy to a
large part of the northeastern region of Brazil, being subject to the regulations of the National
Electric Energy Agency (ANEEL).
According to information from ELETROBRÁS (as of 31 December 2022), the CHESF
System consisted of the following transmission lines: twelve LTs of 69 kV, with a length of
195.54 km; eight LTs of 138 kV, with a length of 462.40 km; two-hundred-forty-three LTs of
230 kV, with a length of 15,678.35 km; and fifty-two LTs of 500 kV, with a length of 5,663.03
km.
In response to the consultation formulated by the Investigation Committee, CHESF
informed that its transmission network had:
- 210 points of intersection, with voltage levels of 138 kV, 230 kV, and 500 kV;
- 26 points of intersection between CHESF and TAESA transmission lines; and
- 01 point of intersection along the 138-kV transmission line, which was being
inspected at the time of the accident.
The flights for inspection of CHESF transmission lines took place under the
responsibility of the Paulo Afonso’s Aviation Division (DOSPA), which had a fleet of two
airplanes and four helicopters, whose maintenance was provided by an outsourced
company.
At the time of the accident, DOSPA had a team of six pilots: four of them operated
only helicopters, while the other two operated both fixed-wing aircraft and helicopters.
The DOSPA pilots would become aware of their participation in inspection flights by
means of e-mail messages.
As CHESF aircraft were operated exclusively by the very company, such aircraft were
not required to be in the Public Specialized Air Service (SAE) Registration Category, nor
was it required for the said company to go through an SAE certification process. According
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to the ANAC’s Resolution nº 659/2022, which regulated the exploration of air services by
Brazilian companies, it would only be required for the company to be certified and the aircraft
to be registered in the SAE category, in the case of provision of paid service.
It is also worth noting that, at the time of the incident, there were no specific regulations
for this type of activity (transmission-line inspections).
ANAC’s Resolution nº 293/2013 established the following definitions for the
Registration Categories:
Art. 60
[...]
II - Public Specialized Air Service (SAE): aircraft used to provide specialized air
services, carried out by a Brazilian legal entity in exchange for fees, in which only
people and materials related to the execution of the service have permission to be
transported; and
[...]
VI - Private Air Services (TPP): aircraft used in services carried out without
remuneration, for the benefit of the owners or operators, comprising recreational or
sporting aerial activities, transport reserved to the owner or operator, specialized air
services carried out for the exclusive benefit of the owner or operator, and without
permission to perform any remunerated air services.
Therefore, the use of the TPP registration category aircraft, for one’s own benefit, was
in accordance with the regulations in force at the time.
In that scenario, since DOSPA was not a Civil Aviation Service Provider (PSAC)
regulated by ANAC, there was no requirement for the implementation of a Safety
Management System (SGSO/SMS), because the aircraft fleet operated under the rules of
the RBAC-91 - “General Operating Requirements for Civil Aircraft”.
Among other objectives, an approved SMS would have the one of establishing a Safety
Policy for the identification of hazards and management of safety risks in the activities, as
well as guarantee the application of the corrective actions necessary to maintain an
acceptable level of performance in terms of safety.
Application of the ABNT NBR 6535:2005
At the time of the accident, the document in force was the ABNT NBR 6535:2005,
which established the “Minimum Criteria for Signalizing Overhead Electricity Transmission
Lines, with a view to Aerial Inspection Safety”.
The aforementioned standard established the following minimum criteria for TL
signage (emphasis added):
3. Requirements
3.1 Signage by painting line supports
Painting is done in orange or red, according to the criteria defined in this section.
For the aircraft pilot, the orange color represents a warning to place himself in a safe
position in accordance with the specific signage found, and the red color indicates
an imminent obstacle. All lines are signposted for either direction of the aircraft.
3.1.1 Intersection of transmission lines
At the intersection of transmission lines, the lower line supports must be painted in
accordance with the following criteria:
a) at least two supports adjacent to the intersection are painted;
b) the segment of the transmission line to be signalized before the intersection is
numerically equal to eight times the difference in the heights of the highest cables of
the two transmission lines (lightning rods or conductors) at the point of intersection,
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for the condition in which this difference is maximum. The support immediately
beyond the calculated distance, from the point of intersection, must also be painted;
c) at least the upper half of the supports is painted, on the external surface facing
the direction of approach of the aircraft;
d) the support adjacent to the intersection is painted red, and the others are painted
orange, according to the color standards in table A.1;
e) the climbing devices on the supports are not painted;
f) when the number of supports between consecutive intersections is equal to or less
than three, all internal supports of the intersections are painted in red.
[...]
3.3 Sphere signage
The spheres for the signage specified in this section must be orange or red, in
accordance with the color standard in table A.1, with a diameter of 600 mm.
3.3.1 At the intersection of transmission lines, lightning rod cables or conductors that
are taller on the upper line are signalized by at least three spheres spaced at a
maximum of 30 m apart.
3.3.1.1 In the case of a transmission line with a taller lightning rod or conductor, the
intermediate sphere is placed at the point of intersection with the axis of the lower
line.
NOTE See application example in figure B.11.
3.3.1.2 In the case of transmission lines with two lightning-rod cables or more than
one conductor of greater height, the spheres are distributed, preferably, alternately
on the lightning-rod cables or on the lateral conductor cables, with the intermediate
one placed at the point of intersection with the axis of the lower transmission line.
3.3.1.3 The highest lightning-rod cable or conductor in each span adjacent to the
support or point of intersection is signalized by a sphere placed at a horizontal
distance of 15 m from the cable furthest from the axis of the transmission line.
3.3.2 At exiting branches or derivations or line terminals, the procedures in 3.3.2.1
and 3.3.2.2 must be adopted.
3.3.2.1 The highest lightning-rod cable or conductor in each span adjacent to the
support or branching point is signalized by a sphere placed at a horizontal distance
of approximately 15 m from the cable furthest from the line axis.
3.3.2.2 In the case of transmission lines with two lightning-rod cables or more than
one conductor cable of greater height, the lightning-rod cables or the lateral
conductor cables are signalized.
The Investigation Committee verified that, in the vicinity of the intersection of the
transmission lines where the accident occurred, the 138-kV LT towers were not signalized
by painting in accordance with the criteria of the ABNT NBR 6535:2005 (Figure 32).
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Figure 32 – Vicinity of the intersection of the 138-kV with the 230-kV transmission lines,
highlighting the lack of signage on the tower (support) of the 138-kV LT.
The 230-kV LT cables had orange warning spheres (Figure 33).
Figure 33 - Location of the warning spheres existing before the accident.

Source: CHESF.
Figure 34 indicates the location of the warning spheres of the electrical cables 1, 2,
and 3, respectively, of the 230-kV LT.
Figure 34 - Identification of the warning spheres of the electrical cables 1, 2, and 3,

respectively, of the 230-kV LT.
At the collision with the transmission line, the 230-kV TL warning sphere number 1 fell
to the ground due to breakage of the lightning-rod cable (Figure 35).
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Figure 35 – Aircraft warning sphere nº 1 on the ground,

due to breakage of the lightning-rod cable of the 230-kV LT.
In turn, the warning sphere nº 2 remained in its position at the intersection (Figure 36).
Figure 36 - Warning sphere nº 2 of the 230-kV LT
With respect to the painting of the unmarked towers close to the intersection, the
Investigation Committee was informed by a DOSPA representative that, on account of an
agreement signed by the companies, the operator of the 230-kV LT would be responsible
for signalizing (painting) the towers (supports) of the 138-kV LT existing on the location,
based on the criteria of the ABNT NBR 6535:2005.
Relatively to compliance with the agreement in question, the fact that the CHESF's
138-kV LT had been installed before the TAESA's 230-kV LT was taken into consideration.
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Still in relation to the signage, one observed that, approximately six months before the
date of the accident, there had been an exchange of messages internally to DOSPA on
identified non-conformities (in light of the ABNT NBR 6535:2005), such as, painted towers
barely visible or without paintings, intersections of transmission lines without signage, in
addition to towers and intersections not duly entered on the tablet and portable GPS devices
used by the pilots.
1.18. Operational information.
The aircraft was within the weight and balance limits specified by the manufacturer.
On the day of the accident (05 June 2022), the PP-MCJ operated from SBSG, fulfilling
the schedule of aerial inspections of transmission lines, comprising the following segments:
- morning period: Natal / Ceará-Mirim / João Câmara / Extremoz / Touros; and
- afternoon period: Natal / Paraíso / Santa Cruz / Currais Novos / Santana do
Matos / Açu / Mossoró.
The aerial inspection scheduled for the morning period was completed.
The flight plan for the segment in which the accident occurred had the flight identified
as type “G” (general aviation), with takeoff scheduled for 15:30 UTC, destined for SBMS
under Visual Flight Rules.
The estimated duration of the flight was 2 hours and 30 minutes, and the declared fuel
endurance was 3 hours and 30 minutes. As an additional piece of information (RMK), the
flight plan records stated that the flight was intended for inspection of transmission lines at
a height of 500 ft. AGL.
The flight was conducted in Class G airspace (outside controlled airspace).
Relatively to VFR flights, the Command of Aeronautics’ Instruction (ICA) 100-12 -
“Rules of the Air”, in force on the date of the accident, established that:
5.2 PILOT’S RESPONSIBILITY
It is the responsibility of the pilot-in-command of an aircraft flying VFR to provide his
own separation from obstacles and other aircraft through the use of vision, except in
Class B airspace, in which separation between aircraft is the responsibility of ATC,
without prejudice to the provisions prescribed in 4.2.1.
The accident occurred in the afternoon period, at the point of the oblique intersection
of the 138-kV LT with the 230-kV LT (Figure 37).
Figure 37 - Geographic location of the intersection of the 138-kV LT

with the 230-kV LT, having the town of Currais Novos as a reference.
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The aircraft fleet operated by DOSPA did not have on-board equipment with audible
and/or visual warnings to alert pilots on the proximity of obstacles, such as transmission
lines.
In order to deviate from the existing intersections of the various transmission lines, in
addition to their permanent concern related to the visual detection of such obstacles, pilots
had to observe the signage of the transmission lines (ABNT NBR 6535:2005), warning them
of the proximity of those intersections.
The Investigation Committee noted that the planning of flights conducted by DOSPA
did not usually include face-to-face briefings. Presence briefings would be important
occasions for dealing with flight specificities, notably those relating to the identification of
hazards, as well as adoption of risk mitigation procedures.
Instead, one found that the briefings were effected via e-mail messages addressed to
the pilots, through which assessments and suggestions could be presented. Such briefings
contained details of the missions, such as dates, routes, and scheduled transmission-line
inspectors. However, there were no considerations on the safety of operations.
As for the debriefings, these were not held, except in some informal and exceptional
situations, such as those in which poor signage of LT towers was reported, or when there
was a need to repeat the aerial inspection of a certain LT.
There were no formal tools that could be used by pilots to inform other sectors of the
CHESF Company on the identification of hazards for the air operations. In specific cases of
poor TL signage, the pilots informally asked the inspectors to report the observed non-
conformities to the various sectors of the company.
In that scenario, there were no policies in place to foster monitoring on the part of
DOSPA concerning the adoption of pertinent measures.
The operator did not have standard operating procedures which, among other aspects,
could established the use of a callout to alert, for example, on the proximity of obstacles and
intersections of transmission lines, weather minimums, vertical and horizontal distances
from transmission lines, or other conditions that could impair air operations on account of
safety reasons.
DOSPA’s pilots had agreed that, during LT inspection flights in model 206 helicopters,
a torque between 72% and 75% (engine operating speed) would be used, implying average
speeds between 85 kt. and 90 kt.
The speeds could be changed, depending on the requests of the inspectors on board,
or the pilots' assessment in relation to the required fuel endurance of the aircraft to reach
the destination and/or alternate aerodromes.
According to a report from the operator's pilots, the PIC used to adopt an inspection-
flight profile which would lead him to remain approximately 5 m above, using the skid
(landing gear) as a reference, and 15 m laterally away from the inspected cables, using the
edge of the main rotor as a reference (Figure 38).
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Figure 38 - Flight profile adopted by the PIC in relation to the inspected LT.
CHESF pilots reported that, during the inspection of the 138-kV LT, in the segment
where the accident occurred, the PP-MCJ would probably be at a speed of approximately
80 kt. and maintaining a height of around 35 m AGL. They added that the PIC of the accident
flight recommended that other pilots stay away from the LT when meteorological
phenomena and/or rain droplets were present during the flight.
1.19. Additional information.
Command of Aeronautic’s Instruction (ICA) 100-4, of 21 July 2021
With respect to the operation of helicopters, the ICA 100-4/2021, “Special Air Traffic
Rules and Procedures for Helicopters”, established the following:
3 VISUAL FLIGHT RULES
3.1 GENERAL CRITERIA
[...]
3.1.3 Outside controlled airspace, below an altitude of 3,000 ft. or a height of 1,000
ft. above the terrain, whichever is greater, the VFR flight of a helicopter will only take
place when, simultaneously and continuously, the following conditions can be met:
a) to maintain flight visibility conditions equal to, or greater than, 1,000 m, provided
that the flight speed is sufficient to see and avoid traffic or any obstacle with sufficient
time to prevent a collision; and
b) to stay away from clouds and to maintain reference with ground or water.
3.2 MINIMUM HEIGHTS FOR VFR FLIGHTS
3.2.1 Except for landing and takeoff operations, or when authorized by the DECEA’s
Regional Organization with jurisdiction over the area in which the operation is
intended, the VFR flight of helicopters will not take place over cities, towns, inhabited
places, or over a group of people outdoors, at a height of less than 500 ft above the
highest obstacle within a radius of 600 m around the aircraft.
3.2.2 In places not mentioned in 3.2.1, the flight will not take place at a height lower
than the one allowing, in the event of an emergency, to land safely and without
danger to people or properties on the surface.
NOTE: The mentioned height must be of at least 200 ft.
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Supplementary Instruction (IS) nº 00-010, of 05 June 2020

The IS dealing with CRM (Crew Resource Management) established criteria and
procedures for CRM implementation and maintenance, as follows:
5.1 INITIAL Provisions
5.1.1 The CRM training is based on the premise that a high degree of technical
proficiency is essential for air operations to be safe and efficient. Mastery of CRM
concepts does not compensate for a lack of proficiency. Likewise, high proficiency
does not guarantee safe operations in the absence of effective crew coordination.
5.1.2 The mastering of concepts requires continuous effort acting at different levels:
knowledge, skills, and attitudes.
5.1.3 The training should focus on teamwork, and not simply treat those involved as
a set of technically competent individuals. It should provide team-members with
opportunities to practice their skills together, performing the roles normally assigned
to them on a day-to-day basis.
5.1.4 The training must provide each team-member with the opportunity to improve
the use of individual characteristics to promote team effectiveness. To achieve this,
the greater each person's awareness of their behavioral repertoire, both in normal
situations and in contingencies, the greater the understanding of the weak points
that require changes to improve the results of the team's work.
5.1.5 The training must lead team-members to remind that attitudes during normal
and routine circumstances have consequences for the team’s behavior in times of
high workload or stress. Similar situations experienced in training will increase the
probability of coping with the stressful situation competently.
5.1.6 The effectiveness of CRM training must be based on the analysis of standard
operating procedures (SOP). The more comprehensive, clear, logically structured,
and updated they are, the better for team performance.
5.1.7 The CRM Training is defined by the following characteristics:
a) Application of human-factors’ principles to improve team performance.
b) Inclusion of personnel involved with the type of aerial operation, which must be
listed in the CRM training program.
c) Insertion of elements of CRM training in all training contained in the Operational
Training Program, so that the CRM philosophy becomes part of the organization's
culture.
d) Focus on people’s attitudes and behaviors as team-members, and the impact they
have on safety.
e) Provision of opportunities for each team member to analyze their own attitudes
and promote appropriate changes, with the aim of optimizing their ability to work as
a team and make timely decisions.
f) Customization in light of one’s target audience, in line with the training needs to
comply with the company's human factors/CRM policy, considering the strategic,
tactical, and operational levels.
5.1.8 The application of CRM in the 'corporate' modality means adding other
segments of the organization that can impact the operation, generating latent failures
that make the system vulnerable, without, however, failing to consider the training
needs of operational staff. The program of CRM training must be constantly
evaluated, as guided in section 5.5 - Evaluation and Validation of CRM Programs, of
the IS mentioned above.
In May 2022, CHESF pilots underwent CRM training, which included the following
curriculum:
- basic conceptualization of Human Factors (HF);
- definitions on Human Factors and Ergonomics;
- study models: Reason and SHELL;
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- training in team resource management;

- communication and decision-making processes;
- individual stress factors and their effects on performance;
- concepts of errors and threats;
- training and maintenance of teams;
- automation;
- case studies;
- situational awareness;
- group techniques;
- administrative activities;
- evaluation activities;
- evaluation of training;
- activities of integration;
- interpersonal dynamics;
The transmission-line inspectors did not participate in the training.
Likewise, in May 2022, DOSPA held an SGSO (SMS) course for its pilots.
Both events were not mandatory according to the existing provisions of the RBAC-91,
under which the PP-MCJ operated.
Furnas’ Field Technical Manual
By way of illustration, Furnas Centrais Elétricas S.A., a subsidiary of Eletrobras that
also operated in the generation, transmission, and commercialization of electrical energy,
prepared, in July 1995, a “Field Technical Manual” dealing with “Aerial Inspection of
Transmission Lines using Helicopters”.
The manual was intended to provide helicopter pilots and line inspectors of the referred
company with a few parameters for the development of the LT aerial inspection activity, and
contained a description of the standards and procedures that should be observed, both by
helicopter pilots and transmission line inspectors during the execution of aerial inspection
services.
To such purpose, an approach was adopted on various technical and safety-related
factors involved in the activity.
Among the topics covered, the responsibility of the helicopter pilot during operations
was defined, as per item 5 below:
5. Helicopter Pilot’s Responsibility
The pilot is primarily responsible for the safety of the aircraft. He must keep
him/herself informed of the weather conditions along routes of flight, and has ultimate
authority to cancel any flight due to mechanical problems, weather conditions, and
other safety-related conditions.
Relatively to the safety of inspection flights, the following aspects were highlighted:
7.2.1. Before the start of every mission, both the pilot and the LT inspector must be
aware of the flight schedule to be accomplished, the refueling points, the overnight
locations, etc.
7.2.2. The LT inspector must also be aware of the topographical characteristics of
the region of the flight, the weather conditions, etc.
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7.2.3. Whenever possible, flying with the sun shining directly ahead in the direction
of inspection should be avoided, as the pilot's visibility is significantly impaired.
7.2.4. To ensure flight safety, the transmission line being inspected must be identified
and signalized, in order to accommodate both possible directions for the inspection.
7.2.5. The height of the aircraft in relation to the ground (distance h, measured in
meters) should be approximately the height of the tower. The lateral distance of the
helicopter relatively to the conductor cables (distance d), should be approximately
15.0 m.
7.2.6. If there are three or more parallel lines, those in the center must be inspected,
with the helicopter being placed to the left or right of the lines, depending on the type
of helicopter used (controls on the right or left side), so that there is no visual
interference between the inspector and the line being inspected.
7.2.7. If the LT crosses a gorge, the helicopter must remain at the height of the
cables.
Furthermore, the manual limited the average speed of the helicopter on an inspection
flight to 30 kt. (55 km/h).
Safety Standards for Patrols
The Comite de Construcción y Patrullaje de Sistemas de Servicio Publico de la
Asociación Internacional de Helicópteros (HAI), through Utilities / Aviation Specialists Inc.
published, in 1995, the compendium “Evitando El Impacto Con Los Cabos”, which
encompassed the Norms de Seguridad para el Patrullaje, with the aim of providing
information for those involved with the construction and maintenance of electrical energy
transmission lines.2
It is important to clarify that the recommendations contained in the publication had an
advisory nature.
Among the subjects presented, special mention should be made of the
“Procedimientos para Patrullaje y Sistemas de Distribución Eléctrica” (Procedures for
Inspection of Electric Power Systems), listed below:
- get familiarized with the electrical distribution system. This will allow the pilot to
anticipate where the cables are, rather than relying exclusively on visual contact
with them. Distribution systems are not static: they are dynamic and always
changing;
- normally, the higher voltage network has to be installed above the lower voltage
wires. It's best to know what voltage to expect in the area you're flying in, so one
knows what to find above or below the lines;
- when inspecting a system you are not familiar with:
. start with the higher voltage system. This will allow one to observe the crossings
of the cables from the higher to the lower point;
. in order to improve inspection quality and safety, make sure the pilot or line
inspector is familiar with the system they will inspect;
. the pilot should focus on identifying the transmission line intersections and other
sensitive issues, allowing the inspector to have the best picture to ensure line
inspection. The inspector must focus on developing good practices and
observation techniques. The pilot and inspector must work together as a team;
. maintain low speed, as this increases the possibility of sighting the cables in
time. An early visual detection is much more effective than slowing down;
2
FEERST Robert A. Evitando El Impacto Con Los Cabos, Utilities/Aviation Specialists Inc.,1995, Traducción por
Asociación Latinoamericana de Aeronáutica (ALA)
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. the lower the voltage on the lines to be inspected, the greater skill will be
required. The complexity of low voltage systems increases the stress level of
the inspection job;
. ask the power company for information and circuit maps of new transmission
lines and projects under construction;
. work together with the energy company in preparing transmission line
intersection programs; and
. do not assume navigation charts are up to date in relation to intersections of
transmission lines.
Among the proposed recommendations to be observed before the flight, the following
ones are worth to be highlighted:
- the pilot and inspectors should hold a meeting to discuss the inspection
environment, the weather, the fuel requirements, the route, any known and/or
recent obstacles, and noise sensitive areas;
- the pilot and inspectors must work as a team. Before each inspection, one
should evaluate the team's experience. One should make adjustments to
ensure maximum safety;
- the pilot must have qualification and be familiar with the helicopter; and the
inspector must be familiar with the system or with the transmission network;
- the team must have extensive knowledge of each member's primary functions.
It is important that the pilot does not get too involved with the inspector's duties;
- one should review inspection procedures, including standardized callouts for
normal and emergency conditions;
- for greater inspection efficiency, the pilot has to identify the angle, speed and
distance of cables and structures, taking into account the inspector's needs;
- one must always keep windows clean;
- one should comply with the plan that was conceived;
- the pilot must avoid operating the helicopter close to its maximum weight; and
- one has to consider the use of personal protective and survival equipment.
In relation to the inspection flight itself, the compendium highlighted that the following
precautions should be taken:
- paying attention to the possibility of the presence of new transmission networks,
supports, and towers. The construction of new roads may indicate changes in
the transmission system;
- not all intersections will be identified. Be alert for other signs of lines “above”
and “below” at points of intersection;
- flights over cables must be carried out above structures (towers) of higher
voltage lines. This will generally ensure that the highest lines are flown over;
- one must ensure that intersections of transmission lines are mandatorily
mentioned in flight;
- keeping the helicopter skids above the highest cable of the inspected structures.
If for any reason it is necessary to operate at heights lower than the highest
cable, speed must be reduced to allow sufficient reaction time for the avoidance
of hidden obstacles;
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- the pilot's main function is to fly the aircraft. He/she has to avoid performing the
inspector’s duties. Working as a team and establishing a CRM concept are
activities that must be continually motivated;
- as new obstacles are encountered during the inspection, take notes of their
location on the navigation charts, maps, or GPS for a review after the flight or
for future reference;
- flights in the direction of the sun, at dusk or at dawn, may reduce one’s ability
to sight cables due to reflection or glare. This must be taken into consideration,
especially when inspecting areas and systems with which the pilot is unfamiliar;
- when terrain conditions permit, inspection flights should be considered on the
windward side of the cables. The pilot should assess wind speed and direction,
trying to fly against the wind;
- avoid judging the distance of cables, especially braided cables, based solely on
visual references. The potential for optical illusions and poor judgment is high;
and
- when the inspection requires close observation of the cables, operations in
hover or at low speed must be considered.
Post-flight procedures:
- after every inspection flight, the crew must hold a debriefing to analyze the flight
performed and catalog new information and/or obstacles that may be important
for future flights.
EASA Community Network - What can you do to reduce the risk of cable collisions?3
On 31 March 2022, EASA (European Union Aviation Safety Agency) published an
article that addressed the subject of Cable Collisions.
According to the text, electrical wires and other cables are statistically one of the most
significant hazards for helicopters, especially for Low Altitude Operations (LALT) and may
result in fatal accidents. The article presents the EASA animation “Helicopter Wire Strike
Avoidance - Wires in the Helicopter Environment” and develops good practices introduced
in the video that can help one avoid wire strikes.
The article contained some recommendations for the various phases of a helicopter
flight in such condition:
- Planning and preparation:
. Undergo a wire-strike safety-training program which implements wire avoidance flying
techniques and procedures in flight, including understanding of hazards, mission
preparation, and Crew Resource Management (CRM);
. Understand the risk of wire strikes and take the necessary precautions, especially
when flying at low altitude;
. Prepare your flight thoroughly and review any known cable installations on the
planned flight path. Every year, thousands of new electrical and communication towers and
antennas and hundreds or thousands of kilometers of wires are added - the situation can
change from one day to another;
3
Available on: https://www.easa.europa.eu/community/topics/cable-collisions
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. Always download the latest version of maps locating wires and other hazards, such
as natural and artificial obstacles, including wind turbines, in your flight area. Familiarize
yourself with the terrain, navigation charts, and obstacles;
. Use, if possible, an aircraft equipped with wire-detection and avoidance equipment,
and wire cutting technologies;
. Using airborne technology for the obtainment of maximum benefit requires dedicated
training.
. Note that pilots often turn off cable or terrain audio warnings as these may disturb
attention during highly critical maneuvers and exceed one’s mental processing capacity.
Detection systems are ineffective when audio warnings are turned off!
. If you are used to operating a helicopter equipped with detection systems, the risk
can increase when switching to a non-equipped helicopter because you are used to, but
won’t receive audio warnings.
- During the flight:
. Do not fly at low altitude unless necessary for the operation;
. Around 40% of the pilots who hit wires despite knowing knew they were there couldn't
see them. Visibility becomes a huge issue when looking at the wires from above. Even when
wires are visible from the ground, they are not consistently visible to pilots in the air;
. At a typical flight speed, most wires are hard to see. Maintain situational awareness
during the whole flight, and ensure there is sufficient clearance from any obstacle on either
side of the flight path and at all heights, especially in mountainous or hilly environments.
Stay focused on the flight and avoid distractions;
. Invite everyone on board to look actively for cables, support structures, terrain,
obstacles, and traffic, especially when the mission requires flying at low altitude;
. It is recommended to make a higher level reconnaissance before descending below
500 ft. and entering a potentially dangerous wire environment;
. Pay maximum attention to the flight path ahead. Make a slow, wide sweep over a 70º
wide field starting from the center of sight;
. Look for wires and indicators which may reveal the presence of wires, such as towers,
poles, and pathways cut out in trees. Expect wires around roads and buildings, and towers
on hills and hilltops;
. In Specialized Air Services, Medical Services, and other critical missions (power line
inspections) performed at low altitude, external influences such as changing wind direction
or gusts can be highly dangerous, especially in mountainous areas. Also be careful with
weather conditions and reduced visibility; and
. Flight preparation and anticipation are of paramount importance. Mission training,
CRM, and experience gathering are essential aspects for the safe conduction of specialized
missions.
The article concludes by stating that even the latest version of maps with obstacle
locations is not a guarantee that all of them have been properly identified.
In addition, the article reminds that all types of wires must be taken into account, such
as transmission line cables, support cables, electrical and communication cables, mobile
tree cables, cable cars, etc. Thin cables are particularly difficult to sight and may be hidden
by trees and other natural or artificial obstacles.
1.20. Useful or effective investigation techniques.
NIL.
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2. ANALYSIS.
The purpose of the flight was to inspect a CHESF 138-kV transmission line in the
segment between Currais Novos and Mossoró in the State of Rio Grande do Norte. The PIC
filed a VFR plan for a flight in uncontrolled airspace, originating in SBSG and landing in
SBMS, at an altitude of 500 ft AGL.
During the inspection flight, the aircraft collided with a TAESA's 230-kV transmission
line near the town of Currais Novos. Subsequently, the aircraft fell into a dam, where it rested
partially submerged.
The PIC had qualification and experience for the type of flight, and held a valid
Aeronautical Medical Certificate.
The records of the aircraft's airframe and engine logbooks were up to date. The CVA
(Airworthiness-Verification Certificate) of the aircraft was valid. There was no evidence of
failure or malfunction of aircraft systems and/or components that might have affected its
performance or control in flight.
The aircraft, registration marks PP-MCJ, was registered in the TPP Registration
Category, and operated under the rules of the RBAC-91.
On account of the dynamics of the collision, the WSPS equipping the helicopter was
not sufficient to minimize the consequences of the impact against the transmission line
cable.
The presence of adverse weather conditions during the operation period had caused
the cancellation of the initial flight of the schedule on the morning of 31 May 2022, leading
the aircraft to return to Paulo Afonso, State of Bahia.
On the day of the accident, the 18:00 UTC SIGWX, with weather information from the
ground surface to FL250, forecast cloudy skies with the presence of Cumulus (CU) and
Stratocumulus (SC) clouds with base at 1,700 ft and top at 6,000 ft; Towering Cumulus
(TCU) clouds with base at 2,500 ft.; and showers of rain.
In turn, the 05 June 2022 FIR-RE GAMET, valid from 12:00 UTC to 18:00 UTC,
forecast the following meteorological conditions for the region: surface visibility of 3,000 m
due to rain; isolated thunderstorms and CB, base at 3,000 ft and top above FL100; isolated
TCU, base at 2,500 ft., and top above FL100; significant cloudiness at low altitude, base at
800 ft and top at 1,400 ft., broken and scattered Cumulus clouds with base at 1,700 ft and
top at 6,000 ft.
Thus, in relation to the weather conditions forecast and observed in the area of the
accident, one found that there was a relatively unstable atmospheric condition, with
restricted visibility, which provided rainy weather, with variable multilayer cloudiness, and
prevailing winds from the South. .
According to the history of meteorological data contained in the INMET meteorological
station map, the average daily precipitation measured in the town of Caicó, located at a
distance of approximately 46.5 NM from the accident site, reached a volume of 43 mm.
In fact, the image of the PP-MCJ in flight, captured by observers near the urban
perimeter of Currais Novos, at a distance of approximately 4 km from the site of the collision
against the 230-kV LT, revealed the presence of precipitation and restricted visibility.
The messages exchanged between the PIC and his working group indicated that he
was concerned about keeping his co-workers updated on the continuation of the LT
inspection schedule, despite the compromised weather conditions throughout the Northeast
region of Brazil.
The calling off of the initial flight of the aforementioned schedule, with the consequent
return of the aircraft to Paulo Afonso, State of Bahia, on the morning of 31 May 2022 on
40 of 46
account of weather conditions, reveals the hypothesis that the PIC felt compelled to continue
the mission.
That said, it seems that the flight of the PP-MCJ outside controlled airspace and below
1,000 ft AGL, may not have been carried out in conditions of visibility equal to or greater
than 1,000 m, and at flight speed sufficient for the avoidance of obstacles, as required by
the ICA 100-4.
Considering that, at the point of collision, the average height of the 138-kV LT was 30
m, and that the helicopter collided with a lightning-rod cable in the upper part of the 230-kV
LT, whose height was 41.66 m, one deduced there was a clear change in the usual flight
profile adopted by the PIC, who used to stay approximately 5 m above and 15 m to the side
of the transmission line being inspected.
With respect to the speed adopted in the inspection, the CHESF pilots reported that
the aircraft speed during the aerial inspection of the 138-kV LT was estimated to be 80 kt.
Therefore, one may assume that such speed hindered the early sighting of the 230-kV LT
and reduced the reaction time for the necessary avoidance.
Taking as a basis the Furnas Centrais Elétricas S.A “Field Technical Manual”, which
dealt with aerial inspections of transmission lines with helicopters, one found that the
referred company recommended an average speed of 30 kt. during the inspection flight. In
turn, the publication “Procedures for Inspection of Electric Power Systems” recommended
the maintenance of low speed so as to increase the possibility of sighting the cables, since
early sight was considered more effective than speed reduction for avoidance of obstacles.
The abovementioned aspects pointed toward a scenario in which, given the
compromise in horizontal visibility, the PIC moved laterally and vertically away from the 138-
kV LT, and was taken by surprise by the lightning-rod cable of the 230-kV LT. It is, thus,
revealed that the PIC, possibly using a speed of 80 kt, did not notice the 230-kV LT in time
to avoid colliding.
In addition to the degraded conditions of horizontal visibility and the possible speed
used, the camouflage effect of the vegetation on the 230-kV LT may have contributed to
reducing the distance necessary to identify and avoid the obstacle in a safe and effective
manner.
Regarding this subject, the article “Wire, The Invisible Enemy”, published in 2017 by
Flight Safety Australia, warned of the fact that the wires could disappear from the eyes and
become invisible, even for a trained crew, and that several aspects can make wires invisible,
such as atmospheric conditions, viewing angle; visual illusions; the pilot's visual field
scanning abilities; the workload in the flight deck; and the camouflage effect of nearby
vegetation.
The European EASA, in turn, published the article “Cable Collisions” in 2022, which
advocated the use of an up to date version of maps showing wires and other hazards, such
as natural and artificial obstacles, wind turbines included. Thus, the lack of mapping of the
intersection of the 138-kV LT with the 230-kV LT on the WAC chart, GPS, and tablet used
by the PIC pointed out to the inadequacy of the set of publications, maps, and software
used.
Given the possibility of failures in the mapping of obstacles, the pilots would have to
pay extra attention to the signage recommended by the ABNT (towers painted red/orange
and electrical cables fitted with warning spheres).
With respect to signage, one observed that, within the scope of DOSPA, approximately
six months before the date of the accident, messages were exchanged, reporting some non-
compliances, in light of the ABNT NBR 6535:2005, such as: towers with barely visible
paintings or without paintings, LT intersections without signage, as well as towers and
41 of 46
intersections without proper inclusion on the tablet and portable GPS devices used by the
pilots.
One found that in the vicinity of the intersection of the 138-kV LT with the 230-kV LT,
although the electrical cables of the latter were demarcated by orange warning spheres, the
138-kV LT towers were not painted red, as prescribed in the ABNT NBR 6535:2005.
That aspect was considered relevant, since such visual stimulus would warn pilots on
the imminent encounter with an obstacle (intersection with the other transmission line),
especially considering that the aircraft did not have obstacle-proximity warning systems.
The Investigation Committee also identified that the failures in the 138- kV LT signage
occurred despite the declared agreement between CHESF and TAESA, whereby the
provider of the 230-kV LT would be responsible for signalizing the 138-kV LT towers. Thus,
the lack of adequate supervision and an effective organizational process, enabling a timely
feedback on information regarding LT signage, impacted the risk management of that air
operation.
Although the CHESF pilots had done CRM courses, the inspectors had not participated
in that type of training. Despite not being mandatory, the presence of these latter
professionals in the course could have become an important tool for preventing accidents
of the same nature, as there would be a standardization of attitudes and behaviors, in
addition to improving the crew’s synergy.
In such scenario, one identified that pilots and line inspectors were not used to adopting
any type of standardized communication (callouts) capable of optimizing the exchange of
operational information between them, and that would be a crucial tool for the obtainment of
an effective CRM.
Finally, since the operator did not constitute a PSAC regulated by the ANAC, the
aircraft fleet operated under the rules of the RBAC-91, and implementation of an SMS was
not required. From such perspective, there was not a formal safety policy for identification
for the identification of hazards and management of safety risks in transmission-line
inspection operations.
3. CONCLUSIONS.
3.1. Findings.
a) the PIC held a valid CMA (Aeronautical Medical Certificate);
b) the PIC held a valid HMNT rating (Single Engine Turbine Helicopter);
c) the PIC had qualification and experience for the type of flight;
d) the aircraft had a valid CVA (Airworthiness-Verification Certificate);
e) the aircraft was within the weight and balance limits specified by the manufacturer;
f) the records of the airframe and engine logbooks were up to date;
g) the helicopter was fitted with a Wire-Strike Protection System (WSPS);
h) no formal briefing was held before the mission;
i) there were active meteorological phenomena in the region where the accident
occurred, such as isolated thunderstorms, cumulonimbus clouds, towering cumulus
clouds, as well as rain showers with restricted visibility;
j) the aircraft was performing a flight for inspection of the CHESF (Companhia Hidro
Elétrica do São Francisco) Company’s transmission lines;
k) the WAC 3018 Chart used in the inspection was out of date;
42 of 46
l) the intersection of the 138-kV LT with the 230-kV LT was not mapped in any of the
resources being used (WAC chart, GPS, and tablet);
m) the 138-kV LT towers were not painted red, as required by the ABNT NBR
6535:2005;
n) the speed normally used in the operation was 80 kt, a fact that reduced the reaction-
time to avoid obstacles;
o) during the inspection of the 138-kV LT near the town of Currais Novos, there was
a collision with the 230-kV LT;
p) after the collision, the aircraft fell into a dam and submerged;
q) the aircraft was destroyed;
r) the PIC and both inspectors suffered fatal injuries.
3.2. Contributing factors.
Communication – undetermined.
During LT-inspection flights, pilots and inspectors would not make use of any type of
standardized communication (callout) capable of optimizing the exchange of operational
pieces of information, especially those proper for risk situations, such as proximity to
obstacles, including intersections of transmission lines.
Adverse meteorological conditions – a contributor.
In the region of the accident, at the approximate time of the occurrence, there was
presence of significant meteorological phenomena, such as TCU clouds, precipitation, and
restricted visibility, which reduced the possibility of sighting the 230-kV LT in a timely
manner.
Crew Resource Management – undetermined.
Although CHESF pilots underwent CRM training, the lack of participation of LT inspectors in
that training may have affected the use of human resources available for the operation of
the aircraft, especially in relation to the communication between members of the crew.
Organizational culture – undetermined.
In the phase of preparation for the flight, briefings were usually held by means of e-
mails addressed to the pilots. Such briefings did not have considerations related to the safety
of operations. Likewise, debriefings were not normally held, except in some informal and
exceptional situations.
These informally-adopted procedures point towards an ineffective safety culture, since
issues relevant to flight compliance, notably those relating to operational safety, would not
be dealt with effectively.
Piloting judgment – undetermined.
Considering that, according to reports, the PP-MCJ maintained a speed of 80 kt. during the
LT-inspection flight, one assumes that such fact may have hindered the early sighting of the
230-kV LT and the timely avoidance of the obstacle against which the helicopter collided.
Motivation – undetermined.
Bearing in mind that, at the beginning of the operation on 31 May 2022 the prevailing
meteorological conditions influenced the flight schedule planned for the week in which the
accident occurred, and also that the messages exchanged between the PIC and his working
group showed a concern to keep the crew updated on the continuation of the LT-inspection
schedule despite the compromised weather conditions, one cannot rule out the possibility
43 of 46
that self-imposed pressure may have reinforced the team's motivation to operate in spite of
the known restrictions to visibility.
Perception – undetermined.
It is plausible that there has been a reduction in the PIC's situational awareness,
impairing his ability to recognize and understand the risks arising from an aerial operation in
a condition of degraded visibility, as well as his ability to project the consequences of those
risks.
Flight planning – a contributor.
There was inadequacy in the work of preparation for the flight, as there was no prior
knowledge of all the operational conditions along the route, such as the unmarked
intersection of the CHESF’s with TAESA’s transmission lines.
Decision-making process – a contributor.
In spite of the presence of meteorological phenomena in the region where the accident
occurred, the decision made to continue the mission revealed flaws in the perception,
analysis, and selection of alternatives appropriate for the situation experienced.
Organizational processes – a contributor.
Near the intersection of the 138-kV LT with the 230-kV LT, the investigators found that,
even though the 230-kV LT electrical cables were signalized by orange spheres, the 138-
kV LT towers were not painted in red, as required by the ABNT NBR 6535:2005.
The deficiencies observed in the signage of the 138-kV LT occurred despite the
declared agreement between CHESF and TAESA, whereby the 230-kV LT providing
company would be responsible for signalizing the 138-kV LT towers. Thus, the lack of
adequate supervision and an effective organizational process, which would have enabled a
timely feedback of information concerning the LT signage, affected the risk management of
the air operation in question.
Support systems – a contributor.
There was lack of organizational support for providing the pilots with up-to-date
information on the location of intersections of transmission lines in the accident region.
Despite availability of the WAC 3018, 6th edition (year 2020), the out-of-date chart
found on board the PP-MCJ was from 2004, and did not feature the intersection of the
transmission lines. Likewise, the tablet and the portable GPS equipment did not contain the
required up-to-date information.
4. SAFETY RECOMMENDATIONS
A proposal of an accident investigation authority based on information derived from an
investigation, made with the intention of preventing accidents or incidents and which in no case
has the purpose of creating a presumption of blame or liability for an accident or incident.
In consonance with the Law n°7565/1986, recommendations are made solely for the benefit
of safety, and shall be treated as established in the NSCA 3-13 “Protocols for the Investigation of
Civil Aviation Aeronautical Occurrences conducted by the Brazilian State”.
To Brazil’s National Civil Aviation Agency (ANAC):
A-069/CENIPA/2022 - 01 Issued on 05/16/2024
44 of 46
A the relevance of issuing safety-focused guidelines on the activity of transmission lines

aerial inspection, taking into account international guidelines and studies published on the
subject.
Disseminate the lessons learned from this investigation to the CHESF Company
(Companhia Hidro-Elétrica do São Francisco), so that the referred operator can apply the
best practices during operations for inspection of transmission lines.
Disseminate the lessons learned from this investigation to companies dealing with aerial
inspections, with the purpose of alerting them of the risks arising from deficient signage of
overhead transmission lines, based on the provisions of the ABNT NBR 6535:2005.
To Brazil’s National Electric Energy Agency (ANEEL):
Ensure the adequacy, on the part of concessionaires of overhead transmission lines

operating in different regions of the country, of the criteria established in the ABNT NBR
6535:2005.
5. CORRECTIVE OR PREVENTATIVE ACTION ALREADY TAKEN.

After the accident, the towers of the 138-kV LT were signalized by means of painting
near the intersection with the 230-kV LT, as recommended in the ABNT NBR 6535:2005
(Figure 39).
Figure 39 - Painting of 138-kV LT supports (towers), after the accident.
The CHESF, through Paulo Afonso’s Aviation Division (DOSPA) did the following:
- undertook studies, with the purpose of updating the criteria and operational conditions
required for the conduction of VFR flights with helicopters in the inspection of transmission
lines. The study addressed, among other aspects, the minimum atmospheric conditions for
the execution of aerial inspections, the minimum and maximum speed limits, altitude of the
flight and distances from the LT axis, conditions for leaving and entering the LT lanes, and
minimum horizontal and vertical limits of visibility;
45 of 46
- in the planning of aerial inspections, a briefing was included involving pilots and line
inspectors before each segment of flight, with the aim of comparing the data entered in the
GPS and in navigation charts for the transmission line to be inspected, with emphasis on
the intersections of transmission lines, obstacles, and changes of direction along the route.
DOSPA, in coordination with the georeferencing sector of the CHESF Company:
- updated the location of the intersections of CHESF’s with TAESA’s transmission lines
on the GPS equipment made available to its pilots and line inspectors;
- implemented an alert system in the GPS equipment used by CHESF pilots, with aural
and light warnings concerning proximity of intersections of transmission lines;
- introduced protocols, regulating the update of data relating to the signage of
transmission line intersections, based on information obtained by line inspectors during
inspection flights;
- included CHESF transmission lines in the georeferenced maps on tablets used by
pilots and line inspectors; and
- established protocols for the analysis of contingent non-conformities or incidents
verified during inspections, documenting and forwarding them to the various CHESF sectors
interested in the matter, for the taking of necessary measures.
On May 16th, 2024.
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COMANDO DA AERONÁUTICA

CENTRO DE INVESTIGAÇÃO E PREVENÇÃO DE

1.1. History of the flight. ........................................................................................................ 7

3.1. Findings. ...................................................................................................................... 42

GLOSSARY OF TECHNICAL TERMS AND ABBREVIATIONS

Figure 1 – View of the PP-MCJ at the accident site.

The aircraft was destroyed.

1.4. Other damage.

1.5.5. Validity of medical certificate.

Figure 2 - View of the PP-MCJ aircraft. Source: Jetphotos.net

Figure 3 shows a detailed view of the upper wire-cutter.

Figure 3 - Detailed view of an upper wire-cutter.

1.7. Meteorological information.

Figure 4 - SIGWX chart (from surface to FL 250). Source: REDEMET.

- isolated CB clouds (base at 3,000 ft and top above FL100);

Figure 5 - Satellite Image of the region where the accident occurred.

The records of daily precipitation measured in meteorological data contained in the

According to reports made by observers in the town of Currais Novos, located

Figure 11 - Intersection of the 138-kV LT with the 230-kV LT.

Figure 12 - Vertical arrangement of LT cables.

Figure 13 - Illustrative image of lightning-rod cables on the top of a LT.

Figure 14 – Croquis of the accident.

Figure 15 – Croquis with the dimensions of the LT and terrain elevations.

Figure 16 - Aspect of the partially submerged wreckage.

Figure 17 – Lightning-rod cable segment broken in two places (highlighted ends).

Figure 18 – Contact marks (grooves) between the lightning-rod cable

Figure 19 - View of the two main rotor blades.

Figure 20 - Upper segment of the sectioned main-rotor mast (A) and

Figure 21 - Detail of the aircraft's lower wire-cutter with no traces

Figure 22 - Enlarged image of the aircraft's lower wire-cutter.

Figure 24 - General view of the upper wire-cutter with the

Figure 25 - General condition of the upper wire-cutter.

Figure 26 – Lightning-rod cable markings on the rear cross tube.

Figure 27 - Damage to the left-hand horizontal stabilizer, with sectioning

Figure 28 - View of the tail rotor and transmission box.

The aircraft's fuel tank sustained rupture (Figure 29).

Figure 29 – Aircraft debris, with the fuel tank in highlight.

1.13. Medical and pathological information.

Figure 30 - Influence of rain droplets on the windshield of a helicopter,

Figure 31 - Measurement of displacement (9.24 m) calculated

The 230-kV LT cables had orange warning spheres (Figure 33).

Figure 33 - Location of the warning spheres existing before the accident.

Figure 34 - Identification of the warning spheres of the electrical cables 1, 2, and 3,

Figure 35 – Aircraft warning sphere nº 1 on the ground,

Figure 36 - Warning sphere nº 2 of the 230-kV LT

Figure 37 - Geographic location of the intersection of the 138-kV LT

Supplementary Instruction (IS) nº 00-010, of 05 June 2020

- training in team resource management;

To Brazil’s National Civil Aviation Agency (ANAC):

A-069/CENIPA/2022 - 01 Issued on 05/16/2024

A the relevance of issuing safety-focused guidelines on the activity of transmission lines

A-069/CENIPA/2022 - 02 Issued on 05/16/2024

A-069/CENIPA/2022 - 03 Issued on 05/16/2024

To Brazil’s National Electric Energy Agency (ANEEL):

A-069/CENIPA/2022 - 04 Issued on 05/16/2024

Ensure the adequacy, on the part of concessionaires of overhead transmission lines

5. CORRECTIVE OR PREVENTATIVE ACTION ALREADY TAKEN.

Figure 39 - Painting of 138-kV LT supports (towers), after the accident.

On May 16th, 2024.