Embraer EMB-110 Bandeirante

The following findings were identified:
- The total weight of the aircraft upon departure from Belém Airport was 650 kilos above MTOW,
- The cargo was not stowed in the cabin but simply stored on the floor,
- The left engine was not providing power at impact and the aircraft entered a left turn and then an uncontrolled descent until impact with the ground,
- Failure of the left engine due to the presence of an aluminum part obstructing the fuel pipe. Metallographic analyzes confirmed that this aluminum part likely came from a thread of the fuel pump,
- Complacency of the crew who failed to follow the published procedures of the operator.

The following findings were identified:
- The wreckage was found 3 km south of the intended route,
- The aircraft struck a tall tree with its right wing 390 metres above ground, flew for another 1,300 metres then crashed,
- The minimum safe altitude for the area is 5,400 feet,
- No technical anomalies were found on the aircraft,
- Investigations were unable to determine the exact cause why the crew failed to comply with the minimum safe altitude,
- The captain had insufficient rest time prior to the flight and consumed an above-therapeutic level of antihistamine prior to the flight, which may have affected his capabilities to fly,
- The operator's published standard operating procedures for the Embraer Bandeirante aircraft were inadequate,
- Weather conditions were considered as good with a 40 km visibility, scattered clouds at 2,200 feet and no wind,
- The total weight of the aircraft was just below the MTOW.

Controlled flight into terrain after the crew continued the descent to Goroka under VFR mode in IMC conditions. At the time of the accident, the aircraft was one km off course and at an insufficient altitude (minimum altitude is fixed at 14,000 feet).

The following factors were identified:
- It was not possible to examine the debris of the aircraft to determine the contribution of this factor to the failure of the left engine.
- It is possible that the failure to carry out a type B2 inspection and/or to carry out a type A1 inspection by an unqualified person may have contributed to the occurrence of a low oil pressure emergency, due to material deterioration or inadequate services. The impossibility of examining the aircraft could not determine this aspect.
- The owner of the air taxi company participated due to lack of adequate supervision in the planning of operations, at the technical, operational and administrative levels. This deficiency can be characterized, among other things, by the owner of the company that allowed the aircraft to fly with the type B2 inspection expired; by the excessive amount of fuel, when refueling in Manaus; by the unreasonable number of people on board, causing the aircraft to fly with excess weight, and still, by the receipt of pilots' salary to be conditioned to the accomplishment of the fateful flight.
- Errors were made by the aircraft crew due to the improper use of the resources available in the cabin, intended for the operation of the aircraft, due to non-compliance with operational rules.
- There was a mistake made by the crew due to the inadequate preparation for the flight, assuming numerous failures, such as: the non conference, by the pilots, of the cargo and passengers manifest; the lack of the realization of a briefing and still, to accept an aircraft for a flight, being the same with its inspection not carried out.
- An error was made by the crew due to inadequate evaluation of certain aspects of the flight. Such deficiency was evidenced when the first sign of failure of the lubrication system occurred, after twenty minutes of flight, and even so, they decided to proceed with the flight, when the most sensible and safe would be the return, immediately, to Manaus.
- The airline's support staff participated in the planning of weight and balance of the aircraft and the number of passengers on board, providing incorrect information to the aircraft's crew members. In addition, the mechanic who performed the A1 type inspection was not qualified for the function.
- There has been intentional non-compliance by the crew members with the operational rules established by the aircraft manufacturer.
- The Commander did not foresee what was predictable, for lack of caution, thus intentionally increasing the risk margin of the mission.

Findings as to Causes and Contributing Factors:
1. At the time of the occurrence, the base of the cloud at Little Grand Rapids was between 100 and 300 feet agl, with fog to the east of the airport, and the visibility was one to two miles.
2. The aircraft was flown in marginal weather at low level, below the minimum en route altitude for commuter operations and below the MDA for the NDB A approach at Little Grand Rapids. The MDA for the approach was 1 560 feet asl, 555 feet above the airport elevation.
3. While the aircraft was being manoeuvred at very low level in marginal weather, it descended after an abrupt turn, and flew, in controlled flight, into the terrain.
Other Findings:
1. At both take-off and landing, the aircraft was about 1 000 pounds heavier than the relevant maximum allowable weight.
2. The GPS installed in C-GVRO was not approved as a primary navigational aid. The available information indicates that the flight crew used the GPS as a primary navigational aid during the last approach to Little Grand Rapids.
3. The aircraft was not equipped with a GPWS, nor was it required to be by regulation.
4. The weight and balance report that was submitted to Transport Canada, required for the importation of C-GVRO, contained numerous discrepancies; the report was not reviewed for accuracy by Transport Canada.
5. The emergency locator transmitter (ELT) produced a very weak signal because the antenna cable had been installed with little slack, and it pulled out of the antenna fitting during impact.
6. It could not be determined whether the presence of carbon monoxide and diphenhydramine in the captain's body affected his decision making and level of alertness.
7. The company, which had been an air taxi operator, did not effectively manage either the addition of the more complex commuter operations or the introduction of the larger Bandeirante aircraft.
8. The difficulty that the company had in the transition to commuter operations and in the introduction of the Bandeirante aircraft was underestimated by Transport Canada.
9. There were inadequacies in TC=s oversight, whereby the post-certification audit of the company was not conducted, thus eliminating an important mechanism by which TC could have found, and addressed, the inadequate safety management practices, non-conformance with pilot training requirements, and related operating irregularities.
10. The pilots had passed their flying proficiency and medical tests, but they had not completed elements of pilot training requirements with respect to servicing and operational control and right seat conversion as prescribed by TC. Also, no company pilot had received required training in the use of onboard survival or emergency equipment.
11. There was no indication found of any pre-impact failure or malfunction of the airframe, flight controls, or engines.
12. The aircraft was not equipped with either a CVR or an FDR; TC had given the company an exemption to operate without a CVR until 01 August 1998, and the aircraft was not required to be equipped with an FDR.
13. The absence of recorders on this aircraft, which was configured to carry 20 people, left many of the otherwise ascertainable facts associated with the accident unknown and reduced the opportunity of uncovering risks to safety associated with the flight.
14. Conditions were conducive to the pilot experiencing a false sensation that the aircraft was climbing (somatogravic illusion) after increasing the engine power, and he may have been manoeuvring to avoid an abandoned fire tower.

The crew continued the approach below MDA until the aircraft struck obstacles and crashed.