Manaus-Aeroclube de Flores

Contributing factors:
- Control skills - undetermined
The damage observed in the hot engine section components indicated the occurrence of an extrapolation of the ITT limits, which may have caused the melt observed in the blades of the compressor turbine. Thus, in view of the expected reactions of the engine during the use of the EPL, it is possible that there has been an inappropriate use of this resource and, consequently, an extrapolation of the engine limits, especially in relation to the temperature.
- Training - undetermined
The investigation of this accident identified issues related to the operation of the aircraft that could be related to the quality and/or frequency of emergency training with engine failure.
- Piloting judgment - undetermined
It is possible that the loss of lift produced by the flap retraction resulted in a sinking that prevented the plane from reaching the SWFN runway with the residual power that the engine still provided. In this case, an inadequate assessment of the effects of such action on the aircraft performance under those conditions would be characterized.
- Memory - undetermined
It is possible that the decisions made were the result of the pilot's difficulty in properly recalling the correct procedures for those circumstances, since these were actions to be memorized (memory items).

Contributing factors:
- Flight indiscipline – a contributor
The pilot failed to comply with the minimum fuel requirements laid down in the regulations, providing conditions for both engines to stop operating in flight, due to lack of fuel.
- Piloting judgment – a contributor
It was found in this flight an inadequate evaluation for certain parameters related to aircraft operation, particularly with regard to the influence of the chosen flight level on fuel consumption. This misjudgment led to the decision to proceed with the flight to the Aerodrome where it was intended to land, to the detriment of the more conservative option of finding a suitable place for an intermediate landing and a refueling, which led to the depletion of usable fuel in flight.
- Flight planning – a contributor
Inadequate flight preparation work, especially with regard to fuel calculation and cruise level selection, has degraded the safety level and also contributed to the actual accident.
- Decision-making process – undetermined
Difficulties in perceiving, analyzing, choosing alternatives, and acting appropriately due to inadequate judgment, may have resulted in poor assessment of flight parameters (available fuel, distance to destination, verified consumption, etc.), which may have favored the occurrence of lack of fuel failure.

It was determined that the loss of control results from the fact that the flight controls were locked. Investigations show that the pilot failed to prepare the flight properly, that he did not follow the pre takeoff checklist and that he rushed the departure. It was reported that the operator was using since two years a control lock that had not been approved by the Civil Aviation Authority, and that no procedure had been put in place place concerning this lock system.