Goiânia

The following factors were identified:
- Attention – undetermined.
It was found the possibility that the PT-ONJ aircraft crew had their attention (focused vision) on the runway at the expense of maintaining proper separation with the terrain on a visual approach.
- Piloting judgment – a contributor.
Regarding the approach to landing profile, there was an inadequate assessment of the aircraft's operating parameters, since the downwind leg was elongated by a significantly greater distance than that expected for a "Category B" aircraft in landing procedures under VFR.
- Memory – undetermined.
It is likely that, based on the experience of ten years of operation in a company governed by the RBAC 121, the PIC procedural memory has influenced the decisions made concerning the conduct of the aircraft. The habit of performing long final approaches in another type of operation may have activated his procedural memory, involving cognitive activities and motor skills, making the actions automated in relation to the profile performed in the accident.
- Flight planning – undetermined.
A possible non-use of the available aeronautical charts (CAP 9453 and WAC 3189), which were intended to meet the needs of visual flight, may have contributed to low situational awareness about the characteristics of the relief around the SNCT Aerodrome and the presence of the power grid that interfered with the aircraft's landing approach.

One should not rule out the hypothesis of a possible malfunction of the aircraft's angle-of-attack control system, considering that the records related to the provision of the calibration service (a necessary condition for the proper functioning of the referred system, and prescribed in the aircraft's maintenance manual) were not identified in the pertinent
control documents.

The pilot intentionally changed his routing for Itapaci where the landing zone was not approved for flight operations. During the landing, the plane struck the ground before the planned zone and crashed. The pilot violated the rules established by the authority.

The following findings were identified:
- The copilot was not certified in the C525 type aircraft,
- The aircraft was above the maximum landing weight limit, but within the balance limit,
- On 13JUN2014, there was a NOTAM in force, informing the prohibition of jet aircraft operation in SWNH,
- The pilot acted incorrectly on the handle of the auxiliary gear control, thinking that he was applying the emergency brake, making the braking of the aircraft impossible.
- The activation of the incorrect lever for the emergency braking of the aircraft was due to insufficient training received by the pilot for the use of the system in question, thus compromising the proper management of the abnormal condition.
- The emergency brake actuator handle of the aircraft was located outside the pilot's sight field, which, together with the lack of knowledge about the correct lever to be activated for emergency braking, favored the pilot's automatic response in triggering the lever that was most adjusted and visually available on the panel - the emergency landing gear drive lever.
- The instruction that the pilot received to operate the Cessna aircraft, model 525 did not emphasize in the theoretical phase the proper use of the emergency brake, nor contemplated training for the use of this system.
- Despite having a lot of experience in aviation, the pilot was little experienced in the aircraft and still did not know basic functionalities like the use of the emergency brake and the engine shutdown through the evacuation checklist procedure.

The following findings were identified:
- Factors, such as obesity and sedentariness, associated with the high workload in the moments preceding the collision with the hill, may have contributed for the task demand to exceed the margins of safety, resulting in wrong decision-making by the pilot.
- Upon facing adverse meteorological conditions and being aware that aircraft which landed before him had reached better visibility in altitudes below 3,500 ft. on the final approach of the VOR procedure, the pilot may have increased his level of confidence in the situation, to the point of descending even further, without considering the risks involved.
- The weather conditions encountered in the final phase of the flight may have aggravated the level of tension in the aircraft cabin to the point of compromising the management of the situation by the pilot, who delegated responsibility for radiotelephony communication to a passenger.
- If one considers that the pilot may have decided to descend below the minimum safe altitude in order to achieve visual conditions, one may suppose that his decision, probably influenced by the experience of the preceding aircraft, was made without adequate evaluation of the risks involved, and without considering the option of flying IFR, in face of the local meteorological conditions. In addition, the pilot’s decision-making process may have been compromised by lack of information on Mount Santo Antonio in the approach chart.
- The primary radar images obtained by Anápolis Control (APP-AN) indicated the presence of thick nebulosity associated with heavy cloud build-ups on the final approach of the VOR procedure. Such meteorological conditions influenced the occurrence, which culminated in the collision of the aircraft with Mount Santo Antônio, independently of the hypotheses raised during the investigation.
- The final approach on the course 320º, instead of 325º, made the aircraft align with the hill with which it collided.
- Mount Santo Antonio, a control obstacle on the final approach in which the collision occurred, was not depicted in the runway 32 VOR procedure approach chart, in discordance with the prescriptions of the CIRTRAF 100-30, a fact that may have contributed to a possible decrease of the situational awareness.

Failure of both engines in flight due to fuel exhaustion. The following contributing factors were identified:
- Poor judgment on the part of the pilot who considered that the quantity of fuel present in the tanks before departure was sufficient, which was not the case,
- Poor flight planning on part of the pilot who miscalculated the fuel consumption,
- The pilot failed to follow the procedures related to fuel policy.

Poor approach configuration on part of the crew who landed the aircraft 750 metres past the runway threshold, reducing the landing distance available. The following contributing factors were identified:
- The crew completed an unstabilized approach,
- Poor approach planning,
- Limited visibility due to the night and poor weather conditions,
- The braking action was low because the runway surface was wet,
- The crew failed to initiate a go-around procedure.

The pilot decided to continue the approach in a flapless configuration and at an insufficient speed, which caused the aircraft to stall on short final.

Wrong approach configuration on part of the crew who continued the approach while the aircraft was not properly aligned with the runway centerline.

It is believed that the pilot lost control of the aircraft in poor weather conditions after he suffered a spatial disorientation. The following contributing factors were identified:
- Poor flight preparation,
- Poor weather conditions with atmospheric turbulences,
- The pilot showed anxiety and complacency,
- The pilot was not properly licensed to operate in IFR conditions,
- The pilot was inexperienced,
- The pilot's actions were likely inappropriate while facing an unexpected situation.