Campinas-Viracopos

Contributing Factors:
- Control Application - contributed.
The difficulty in coordinating the aircraft due to its single-engine flight condition indicated that improper control application contributed to the outcome of this event. Additionally, the early configuration of the aircraft, with the landing gear lowered and flaps at 100%, led it to descend on a glide path below the recommended one, affecting the achievement of the necessary parameters for landing.
- Training - contributed.
The training process previously received by the PIC (Pilot in Command) was insufficient, as it did not provide them with the full knowledge and technical conditions required for performing the duties of a pilot in command of the EMB-121 A1, either due to a lack of training or the low quality of the training received.
- Pilot Judgment - contributed.
The inadequate training led to improper evaluations of the parameters related to the aircraft's operation, contributing to the event. This included a poor assessment of the situation and lowering the landing gear and setting flaps to 100% without ensuring that the landing was secured.

It was determined that the “the landing gear failed due to overload in the cylinder structure”. The fracture started in the rear section of the cylinder in a connection hole which served as a tension concentration point, and ended in the front part of the cylinder with its breakage into two parts. Following a failure of the right main gear upon landing in Montevideo on 20 October 2009, the right main landing gear was replaced by VARIG Engineering & Maintenance (VEM), but the organization responsible for the research of damage, the specification of the services necessary for the restoration of airworthiness, and the provision of the services that enabled the restoration of the aircraft to an airworthy condition was not identified. The same aircraft parts were subjected to metallurgical analysis at the Boeing Long Beach Materials, Processing and Physics [MP&P] Laboratories, in Huntington Beach, California, USA; and the technical report issued by Boeing highlighted that in one of the points of origin of the failure, the analysis had identified characteristics similar to a pre-crack point, which would have begun earlier, probably due to overload. In the tasks that led to the restoration of the aircraft airworthiness after the accident in Uruguay in 2009 (Hard-Landing), and also in subsequent periodic inspections, the existence of pre-crack traces resulting from a previous overload condition may not have been identified, something that could have resulted in a point of stress concentration.

A loss of hydraulic fluids occurred on a hose separating a fitting from a pump on the right engine, causing the malfunction of the primary hydraulic system and resulting in the degradation of the mechanical system of the landing gear control command.

The following findings were identified:
- There was the participation of factors, with their own characteristics, that caused failures of attention, judgment and perceptual evaluation of distances and temporality. The qualitative training deficiency, the lack of cabin resource management and the low situational alert were significant contributing factors to the accident.
- PF has performed poorly in the use of the correct piloting technique in the combination of Speed x Ratio of Descent parameters.
- The instructor assigned by the company to supervise the acquisition of operational experience on route had not received specific instruction for the performance of this task. Technical and operational supervision was lacking.
- PF had good flight experience, but not in this type of aircraft. It was in the phase of acquiring operational experience in route. The inadequate action was also due to the little experience in the aircraft and in the circumstance of the operation, which required a quick correction close to the ground.
- The pilots did not adequately utilize the resources available in the cockpit for the proper operation of the aircraft. PF did not make the necessary corrections to modify the aircraft's trajectory, which was its assignment. The instructor (PNF), in turn, did not effectively correct or interfere with the PF flight, which would have been his responsibility since he was the supervisor of the operation. The pilots did not observe, yet, the technical-operational procedure foreseen in the Flight Operations Manual (MOV), regarding the GPWS warning. The crew did not observe that the warning determined an unsafe condition close to the touch. It was characterized an ineffective fulfillment of the tasks assigned to each crew member, besides the non-observance of the operational rules.
- On the IMC approach made, the PF varied the parameters, remaining high on the ramp. Upon reaching visual conditions, the PF increased the descent rate of the aircraft. The PNF, concerned with locating the runway, did not consider an inadequate PF correction.
- The PF, with the intention of reducing the drop ratio, did not apply correctly, in amplitude and in time, the power available in the engines. Near the touch, the PF increased the pitch angle, trying to reduce the drop ratio. Considering the low height (approximately 80 ft) and engine power (IDLE), the aircraft continued with a high rate of descent (approximately 1,800 ft/min), without the action taken by the PF altering its path. The PNF did not interfere in the application of the commands. Therefore, there was inadequate use of the aircraft commands by the crew members, in conditions for which they were qualified.
- The PF, even being alerted by the PNF about the low speed and high rate of descent, thought it was applying an adequate correction, however it kept the aircraft in an incompatible performance for landing. The PNF, despite having experience in flight and in the aircraft, showed a lack of knowledge of its limits regarding the point of irreversibility of an unsafe situation. The PNF was limited to alerting the PF about the situation, not guiding it on the correct way to make the corrections.
The PNF overestimated PF's capacity and did not take or try to take over the controls.
- The pilots were not aware of the maximum rate of descent during the touch for which the aircraft was certified, nor were they aware of the variation of that rate with respect to weight. The availability of the autopilot to the MDA could have minimized the ramp deviation observed.

It was determined that the loss of control during initial climb was the consequence of the decision of the crew to perform training upon takeoff, intentionally reducing power on both engines n°1 and 2. This decision was taken at a critical phase of flight and the copilot-in-command was unable to maintain control of the aircraft, causing the aircraft to lose speed and to stall.
The following contributing factors were reported:
- The captain's experience in such configuration was low,
- Lack of flight safety doctrine in the cockpit during all flight,
- Execution of unauthorized takeoff training under uncontrolled conditions,
- Execution of such take-off training by a person who was not qualified as an instructor.

It was determined that the hydraulic pump n°2 on the engine n°3 failed after takeoff, causing an oil leak and a loss of hydraulic pressure. The undercarriage could be lowered but not locked down while the crew attempted to lower the nose gear manually but doing so, caused the locking pin to obstruct and damage the landing gear extension system. It was also reported that several seals located on hydraulic lines were broken and have not been replaced during the last C check.