Marabá

The following findings were identified:
- Lack of crew coordination,
- The captain was overconfident,
- The copilot showed a lack of self confidence,
- The environment developed in the cockpit on approach allowed the pilots to deviate from the operational tasks primarily related to mutual controls,
- Poor approach and landing planning which required a higher sink rate than normal,
- The crew failed to make an approach briefing,
- Insufficient application of controls,
- The crew completed an unstable approach,
- Weather conditions were below minimums,
- The runway was not equipped with a lighting system but only with PAPIs,
- The crew failed to initiate a go-around procedure as the landing was obviously missed.

A. Human Factor
1) Physiological aspect - Did not contribute to the accident.
2) Psychological aspect - The following psychological variables contributed to the accident:
a) Misleading perception - In the reading of the plan and incorrect heading insertion by the commander.
b) Reinforcement - In the reading and incorrect heading insertion by the co-pilot and heading conference placed by the commander.
c) Marginal attention and level of attention - The non-recognition of conditions that would mean being far from the objective: request for "VHF bridge" when other aircraft were talking normally with the Control; "reception" of commercial stations, and non-receipt of destination NDB, etc.
d) Predisposition - Maintaining the urge to go to the established objective (Belém).
e) Predisposition duration - Maintenance of FL040 for a long time.
f) Reinforcement of predisposition - Reception of boundaries when selecting Belem's radio frequencies.
g) Attention Fixing - Permanent search for headings, radio contacts or river contours, as an alternative, to reach the fixed goal.
h) Blocks - Delays in identifying the initial headings error and plotting itself in navigation.
i) Geographical position error.
B. Material Factor - Did not contribute to the accident.
C. Operational Factor
1) Poor supervision - Inadequate graphical representation of the Computer Flight Plan.
2) Poor cockpit coordination - No supervision of cockpit activities. Actions were not supervised, but imitated.
3) Poor support staff - Lack of radio contact by the operator's Flight Coordination with the aircraft in flight, after the significant landing delay in Belém, thus breaking the chain of events of the accident.
4) Pilot aspect characterized by environmental influence - Difficulties of visualization due to sunset and dry fog: Radio aid markings received from great distances, originating from the ionospheric propagation of electromagnetic waves.
5) Pilot aspect characterized by poor planning - Lack of route letters to cross the flight plan information.
6) Pilot aspect characterized by poor judgment - Inadequate evaluation and use of radio-navigation equipment, resulting in the pursuit of markings without causing tuning and identification.
7) Pilot aspect characterized by other operational factors - Operational doctrine firming.

Double engine failure.