Manaus-Eduardo Gomes

The accident was the consequence of the combination of the following factors:
- Control skills – undetermined.
While facing adverse conditions, the use of controls may have been inappropriate for the situation and may have contributed to the aircraft not being able to maintain a positive climb rate.
- Attitude – undetermined.
Familiarization with the region may have led to an attitude, on the part of the PIC, of minimizing the importance of analyzing adverse weather conditions, to the detriment of compliance with the minimum limits established by the company in its manuals.
- Training – undetermined.
It is possible that, due to possible inadequate training, the SIC did not identify the critical situation that arose shortly after the take-off in time to assist the PIC in maintaining flight control.
- Tasks characteristics – undetermined.
The characteristics present in the type of operation, compliance with schedules without the possibility of delays, due to the runway closing period, may have favored the self imposed pressure on the part of the PIC, leading him to operate with reduced safety margins.
- Adverse meteorological conditions – a contributor.
The conditions at the time of the take-off contributed to the aircraft not being able to maintain the flight with a positive climb rate. The probable occurrence of Windshear determined that the trajectory of the aircraft was modified until its collision with the ground.
- Crew Resource Management – undetermined.
On the part of the SIC, no assertive attitude was perceived in the sense of alerting the PIC that those conditions were not favorable for takeoff. Thus, the crew decided to carry out the take-off despite the company's SOP.
- Organizational culture – undetermined.
The company encouraged compliance with the legs even though, within the planning of flights, there was not an adequate margin of time to absorb any delays. This culture may have influenced the PIC's decision-making, which, despite encountering adverse conditions, chose to take off, since the short time on the ground in the intermediate locations did not allow room for delays.
- Emotional state – undetermined.
The reports indicated that the PIC felt pressured to perform the take-off even in the weather conditions found on the day of this occurrence. Also, according to the interviewees, this pressure would be related to the fulfillment of the flight schedule and the need to keep to the scheduled times. In this way, it is possible that their assessment of the performance of the flight was influenced by the stress resulting from the pressure to complete the flight within the expected time, given the closing time of the runway for works.
- Flight planning – a contributor.
The flight planning was not carried out properly, considering that the planned schedules and routes would end after the closing time of the SBEG runway for works, provided for in the NOTAM. This meant that there was little time to adjust the legs, increasing the workload and stress in the cabin.
- Decision-making process – a contributor.
There was a wrong assessment of the meteorological conditions, which contributed to the decision of performing it in an adverse situation.
- ATS publication– undetermined.
The TWR-EG did not inform, before the take-off, of the changes in the significant weather conditions that were occurring at the terminal, which could have contributed to the PIC's decision-making.

The following findings were identified:
- Attention,
- Judgment,
- Perception,
- Management planning,
- Decision making processes,
- Organization processes,
- Support systems.

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).

The aircraft landed on the water with the landing gear in the down position.
Contributing factors:
- Attitude – a contributor
Failure to comply with the checklist during the pre-flight inspection and the flight itself favored the landing with inadequate configuration. This attitude may have been triggered by the pilot's confidence in his operational capability, because of his long experience in aviation.
- Flight indiscipline – a contributor
Failure to comply with the checklist indicated, in addition to the low level of situational awareness, a low level of concern for the safe conduction of the flight by failing to follow basic procedures set forth in the manufacturer's manuals and current regulations.
- Piloting judgement – a contributor
The pilot's choice not to use the checklist during the flight phases revealed an inadequate evaluation of parameters related to the operation of the aircraft. Improper compliance with the items in the Pre-Flight Inspection Sheet prevented the AMPHIB PUMP 1 and 2 circuit breakers from being rearmed.
- Aircraft maintenance – a contributor
After performing the test of landing gear extension and retraction by the emergency system, the AMPHIB PUMP 1 and 2 circuit breakers were not rearmed, being the aircraft delivered to fly in this condition. The setting recorded on the AIRSPEED switch of the landing gear position warning system computer demonstrated that the scheduled speed of 74kt was not in accordance with the recommended in the 9600-1A installation manual of Wipaire Inc. in its revision G.
- Memory – undetermined
The AMPHIB PUMP 1 and 2 circuit breakers were found disarmed after the occurrence, indicating that, after the completion of the maintenance service, the executor of the tasks probably forgot to comply with the procedures for reconfiguring the aircraft. In addition, it is possible that the pilot's automatism in relation to his way of carrying out the air operations, without the use of the checklist, has prevented the correct perception of the circuit breakers condition and the erroneous positioning of the landing gear.
- Perception – a contributor
The accomplishment of the landing on the water with the aircraft in inadequate configuration for the situation denotes a decrease in the level of situational awareness of the pilot, considering that the necessary factors and conditions for the safety of the operation were not observed.

Collision with a tapir during takeoff, causing severe damages to the right main gear.
The following findings were identified:
- The lack of isolation of the operational area allowed the land animal to enter the runway for landings and takeoffs, contributing to the accident.
- The crew did not notice the presence of the land animal on the runway early enough to abort the takeoff without extrapolating the runway limits and avoiding collision.
- The presence of the land animal (Tapirus terrestris) interfered with the operation and led to the collision of the right main landing gear.

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.

The following findings were identified:
- The external tyre on the right main gear deflated during the takeoff roll,
- The crew retarded the power levers and deployed the spoilers,
- The crew did not use the parachute, judging the relative low speed and thinking this was an optional equipment,
- Technical analysis on the right main gear revealed that the six bolts on the external wheel torque were approximately 90% lower than foreseen, which may contributed to the tyre deflection.

The following factors were identified:
- At takeoff from Coari Airport, the total weight of the aircraft was 6,414 kg, which means 744 kg over the MTOW,
- On board were 26 passengers including 8 children while the aircraft was certified for 19 passengers,
- The left engine fuel pump was completely burnt during the accident but it could not be determined if it failed during the flight or not,
- The crew was not sufficiently trained for emergency situations,
- Poor work organisation,
- Lack of supervision from the operator concerning crew's decisions before and during flights,
- Poor crew coordination,
- Lack of crew communication,
- Non compliance with management techniques,
- Incomplete execution of the actions provided by the emergency checklist.

The failure of the right engine was the result of the failure of the fuel pump due to poor maintenance and a possible use beyond prescribed limits. The presence of iron oxide inside and outside the fuel pump as well as the lack of cleanliness of the internal components indicates a probable lack of maintenance. When the right engine stopped running, the generator No. 1 was then responsible for powering the aircraft's electrical system. As the latter was not in good working order, the primary generator could not withstand the overload and ceased to function, leaving only the battery to power the entire electrical system. To maintain power to critical systems, the crew would have had to select the backup power system. Since after the engine stopped, there was no monitoring of the electrical system, the pilots only realized the failure of the electrical system when they attempted to extend the landing gears. The emergency hydraulic system was then used to lower the gears, after which the crew did not return the system selection valve to the 'normal' position, resulting in the brakes and the steering systems to be inoperative after landing. The chain of failures may be associated with not reading the checklist when performing procedures after the engine failure.
The following contributing factors were identified:
- Poor flight preparation,
- The crew failed to follow the SOP's, and took the decision to initiate the flight with an aircraft that was overloaded by 503 kilos,
- When the emergency situation presented itself to the crew, they failed to follow the checklist,
- On an organizational level, the company did not have an effective personnel training system in place, so that the crew did not have sufficient skills to respond to emergency situations,
- Because the aircraft was overloaded and that one engine was inoperative, the crew was forced to complete the approach with a speed higher than the reference speed,
- An improper use of the controls allowed the aircraft to land 700 meters past the runway 28 threshold, reducing the landing distance available,
- The crew focused their attention on the failure of the right engine and did not identify the failure of the electrical system, which delayed their tasks assignment, all made worse by the failure to comply with the checklist,
- The operations cleared the crew to start the flight despite the fact that the aircraft was overloaded on takeoff based on weight and balance documents,
- The crew did not prepare the flight according to published procedures and did not consider the total weight of the aircraft in relation to the number of passengers on board and the volume of fuelin the tanks, which resulted in an aircraft to be overloaded by 503 kilos and contributed to the failure of the right engine,
- A lack of maintenance on the part of the operator.