Belém-Val de Cans-Júlio Cezar Ribeiro

A. Human Factor
1) Physiological aspect - Did not contribute to the accident.
2) Psychological aspect - The following psychological variables contributed to the accident:
a) Misleading perception - In the reading of the plan and incorrect heading insertion by the commander.
b) Reinforcement - In the reading and incorrect heading insertion by the co-pilot and heading conference placed by the commander.
c) Marginal attention and level of attention - The non-recognition of conditions that would mean being far from the objective: request for "VHF bridge" when other aircraft were talking normally with the Control; "reception" of commercial stations, and non-receipt of destination NDB, etc.
d) Predisposition - Maintaining the urge to go to the established objective (Belém).
e) Predisposition duration - Maintenance of FL040 for a long time.
f) Reinforcement of predisposition - Reception of boundaries when selecting Belem's radio frequencies.
g) Attention Fixing - Permanent search for headings, radio contacts or river contours, as an alternative, to reach the fixed goal.
h) Blocks - Delays in identifying the initial headings error and plotting itself in navigation.
i) Geographical position error.
B. Material Factor - Did not contribute to the accident.
C. Operational Factor
1) Poor supervision - Inadequate graphical representation of the Computer Flight Plan.
2) Poor cockpit coordination - No supervision of cockpit activities. Actions were not supervised, but imitated.
3) Poor support staff - Lack of radio contact by the operator's Flight Coordination with the aircraft in flight, after the significant landing delay in Belém, thus breaking the chain of events of the accident.
4) Pilot aspect characterized by environmental influence - Difficulties of visualization due to sunset and dry fog: Radio aid markings received from great distances, originating from the ionospheric propagation of electromagnetic waves.
5) Pilot aspect characterized by poor planning - Lack of route letters to cross the flight plan information.
6) Pilot aspect characterized by poor judgment - Inadequate evaluation and use of radio-navigation equipment, resulting in the pursuit of markings without causing tuning and identification.
7) Pilot aspect characterized by other operational factors - Operational doctrine firming.

It is believed that the loss of control may have been the result of windshear that existed in the approach path of runway 06.
The following contributing factors were reported:
- The crew did not have sufficient training and experience to manage a windshear situation and thus, was unable to take the appropriate corrective actions,
- Poor crew coordination,
- The captain's experience on this type of aircraft was low,
- Poor supervision,
- Lack of safety culture by the operator.

In-flight collision on approach for unknown reasons.

Wrong approach configuration on part of the flight crew who continued the descent while the aircraft was too high on the glide and unstable with an excessive approach speed. This caused the airplane to land too far down (848 meters past the threshold) a wet runway contaminated by heavy rain falls. In such conditions, the airplane was unable to stop within the remaining distance and overran at a speed of 80 knots. Because the aircraft was unstable and the approach configuration was wrong, the crew should initiate a go-around maneuver.

Probable misjudgement of the distance separating the aircraft and the water surface on part of the flying crew while conducting an approach in marginal weather conditions.