Florianópolis-Hercílio Luz

Controlled flight into terrain.
Contributing factors.
- Attitude - contributed
The fact that the pilot continued the descent visually, not performing the instrument approach according to the IFR flight plan, denoted disregard of the real risks of this action. Thus, his attitude contributed to the inappropriate approach that culminated in the collision with the ground.
- Adverse weather conditions - contributed
Despite the aerodrome presenting ceiling and visibility conditions favorable for visual flight at the time of the accident, it was verified that there was dense fog covering the entire region near the impact site and, therefore, the IFR rules, which determined a minimum altitude of 5,000 ft, should have been observed.
- Emotional state - undetermined
Some events in the pilot's personal life were negatively affecting his emotional state. In addition, the pilot appeared to be more introspective in the period leading up to the accident.
Thus, it is possible that his performance was impaired due to his emotional state.
- External influences - undetermined
The pilot was possibly experiencing difficult events in his personal life. These events could have negatively affected his emotional state.
Thus, the pilot's way of thinking, reacting and performance at work may have been impacted by factors external to work.
- Motivation - undetermined
The pilot intended to return home because he would be celebrating his birthday and that of his stepdaughter.
The audio recording of the pilot's telephony with the GND-FL, shows that he insisted to accelerate his take-off, denoting a possible high motivation focused on fulfilling his eagerness to accomplish the flight. This condition may have influenced the flight performance.
- Decision making process - contributed
The choice to continue the descent without considering the IFR rules, based on an inadequate judgment of the meteorological conditions, revealed the pilot's difficulties to perceive, analyze, choose alternatives and act adequately in that situation.

Contributing factors:
- Application of commands – undetermined
Considering the hypothesis of spatial disorientation, of the disabling type, it is possible that the pilot has reached a situation of complete inability to operate correctly controls the aircraft in order to regain control of the flight.
- Attitude – undetermined
It is possible that the high subordination of the pilot to the requests of his boss has made it difficult for you to position yourself in relation to your limitation in flying at night and in instrument flight meteorological conditions.
- Disorientation – undetermined
Conditions favorable to disorientation, that is, the night flight over the sea, within clouds and manual operation, as well as the dynamics of the aircraft trajectory recorded by the radar, among other factors, make spatial disorientation the main hypothesis for the accident.
- Visual illusions – undetermined
It is also possible that the pilot suffered visual illusions when flying over the sea in night time. When not seeing the lighting on land, and being at night dark, with cloudiness, the pilot may have confused spatial references.
- Instruction – undetermined
It is possible that the lack of familiarity with the English language has made it difficult, in to some degree, knowledge of the resources, equipment and systems present in the aircraft, as well as in the instruction received in a flight simulator.

The following findings were identified:
- The commander was overconfident in himself and the aircraft which led him to lose the critical capacity to discern the risks involved in the procedure that was adopting. Corroborating was the fact that the pilot judged he had much knowledge in this operation and knew exactly how the aircraft responded. It can be inferred there was complacency by the copilot on the actions of the commander, during the approach at high speed, because even feeling uncomfortable, he did not make an incisive interference because he believed in the idea that the commander had done this kind of approach, with high speed, and so knowing what he was doing.
- The pilot failed to identify the location of touch down during landing and not knowing how much runway was remaining, he decided he should not rush, thus demonstrating low situational awareness and lack of awareness, impacting the proper reaction time for the situation (Rush), which was not performed , leading the occurrence in question.
- The crew failed to properly assess the information available like speed and the runway length for the realization of a safe landing, which led to a poor judgment of the situation at hand, making the decision not to adopt the missed approach procedure.
- The distance between the crew, caused unconsciously by the commander's position with excess knowledge in the operation and the aircraft, and the insecurity of the copilot in considering new and inexperienced, resulted in a lack of assertiveness of the copilot to inform, with little emphasis, the commander of his perception of excessive airspeed.
- The crew did not adopt good crew resource management, failing to communicate with assertiveness and share critical information in time prior to landing, allowing the speeding remained present until the touchdown.
- Despite having adequate experience and training, the commander did not use the resources available, such as speed brakes to reduce the aircraft approach speed.
- The variable wind direction and predominantly tail intensity equal to or greater than 10 knots, allowed excessive speed during landing.
- The crew did not adopt good crew resource management, allowing the high speed to remain present until the touchdown.
- The commander thought he would be able to perform the approach and landing with the speed above the expected.

The crew misjudged distance, speed and altitude during an approach completed in marginal weather conditions. The following contributing factors were reported:
- Lack of flight supervision,
- Lack of crew coordination,
- Improper use of engines,
- The pilot-in-command failed to initiate a second go-around,
- Lack of visibility due to poor weather conditions.