Quito-Mariscal Sucre (Tababela)

The following findings were identified:
- The condition of the runway at Cuenca airport, which at the time of the plane's landing was contaminated with water and slippery.
- The landing was made after a non-stabilized approach with a tailwind.
- During seven seconds, the crew continued the approach with an excessive rate of descent of 1,186 feet, 186 feet above the limit of 1,000 feet.
- The non-application of the Maximum Performance Landing procedure recommended by the aircraft manufacturer for landing on contaminated runways.
- The dispatch of the flight with 1,500 kg of fuel more than the amount of fuel usually used for this flight.
- Omission of the runway length calculation necessary to perform the landing using the braking efficiency information.
- The crew's decision to make the final approach with three red and one white lights, using the PAPI system, induced by the information in the Terminal Information document issued by the company, which authorized this procedure.
- The use of confusing terminology in the Terminal Information document, which used terms applicable to the Airbus fleet, instead of Embraer's.
- The crew's decision not to perform the thwarted approach maneuver after the maximum allowable vertical speed was exceeded and visibility was apparently limited after the minima were exceeded.
- Incorrect use of aircraft braking aids, in this case reverse braking aids
- The application of the emergency brake that inhibits the antiskid system.
- Lack of implementation of adequate management of crew resources, particularly within the cockpit.
- Lack of training in the use of tables for track distance calculation.
- In reference to landing conditions, the aircraft needed a runway length of 2,122 metres while the available distance was 1,900 metres.

The Board of Inquiry estimated that the probable cause of this accident was the crew's decision to continue the approach and landing without carrying out the procedures (ABNORMAL AND EMERGENCY PROCEDURES) established by Embraer in the Quick Reference Handbook when a malfunction occurred with the slat/flap system, resulting in a wrong approach configuration.
The following findings were identified:
- The slats were inoperative during the approach and the crew performed five trouble shooting without success,
- Despite this situation, the crew decided to continue the approach, failed to follow the approach checklist and failed to input the reference speed and distance for landing according to circumstances,
- The aircraft landed too far down the runway, about 880 metres past the runway 35 threshold,
- The braking action was low because the runway surface was wet,
- In normal conditions, with flaps down in second position and slats out, the landing reference speed was 119 knots with a landing distance of 880 metres,
- Because the slats were inoperative, the landing reference speed should be 149 knots and a landing distance of 1,940 metres was needed,
- The aircraft passed over the runway threshold at a height of 50 feet and at an excessive speed of 163,8 knots,
- Spoilers were activated 9 seconds after touchdown, 950 metres after the runway threshold,
- Reverse thrust systems were activated 1,280 metres after the runway threshold,
- The crew started to use brakes 2,300 metres after the runway threshold (runway 35 is 3,125 metres long), with the antiskid system activated,
- Due to an excessive approach speed (15 knots above Vref), a too long flare and a too late application of the brake systems, the aircraft could not be stopped within the remaining distance,
- The slats malfunction was the consequence of the failure of several actuators which did not support negative temperatures met during the last flight,
- Since last July 19, the slats failed 53 times on this aircraft, six times during the approach and 47 times in flight,
- The crew failed to initiate a go-around procedure.

Failure of the crew to follow the published procedures following a fire alarm, as stated in the Operations Manual and the late application of the procedures once the decision to abort the takeoff was taken.
Contributing factors:
- Complacency on part of the crew who failed to proceed with a pre-takeoff briefing,
- A fact that influenced the lack of appropriate action from the crew to successfully tackle any emergency,
- Lack of crew resources management,
- The braking coefficient was low because the runway surface was wet.

Wrong approach configuration on part of the crew who decided to continue the approach to Quito Airport, knowing the poor runway conditions, poor weather conditions and the aircraft weight, and his failure to initiate a go-around procedure while forcing the aircraft to intercept the PAPI, causing the aircraft to be unstabilized.
Contributing factors:
- On the date of the incident, the crew did not have specific regulations and operating procedures (the briefing of the operator for the airport in Quito was inappropriate to the existent conditions).
- The fact that the crew still being experienced similar airports in Quito and had not experienced similar weather situations, circumstances that would have allowed a strategy of approximation consistent with the terms of this operation, in particular as regards:
- Calculations in flight for landing runway length,
- Minimum altitude to start the maneuver of changing the path of ILS to PAPI,
- Carrying out a very detailed briefing that allowed unwanted deviations on approach,
- The weather conditions existing at the time of landing (visibility, tail wind and moderate rain).

It was determined that the crew thought the Coca runway was short. To be able to stop the plane on the runway without excessive use of the brakes, the crew decided to land as early as possible. Doing so, the aircraft landed 4,5 metres short of runway. The published procedure request a minimum altitude of 50 feet over the threshold and the AFM showed a landing distance of 930 metres needed at maximum landing weight considering 42° of flaps, speed brakes out, lift dumpers armed, antiskid operative. Wrong approach procedure on part of the crew.

Lack of a positive actions and reaction on part of the crew following the bursting of both tires on the left main gear, causing the aircraft to overrun the runway.

The probable cause was:
- The decision of the instructor captain and his crew to initiate and continue the operation towards Tulcán Airport below minima weather conditions as established in the company's SOPs.
- Inadequate navigation and operation of the aircraft by the pilot-in-command and directed by the instructor captain, consisting of entering the holding pattern of the Tulcán radio beacon with a speed of 230 knots (IAS) and with a banking of 15° exceeding the maximum stipulated speed limit of 180 knots during the entire procedure including the holding pattern and using a banking below the recommended range of 25° to 30°, thus exceeding the lateral navigation and obstacle protection limits of the holding pattern, leading this operation to the collision with Mt El Cumbal.

The accident was the consequence of a controlled flight into terrain after the crew suffered a loss of situational awareness since their attention was focused on aspects that were not related to the flight being executed and therefore neglecting the primary function of flight which is the control of the aircraft and decision making.
The following contributing factors were identified:
- The crew failed to maintain a sterile cockpit situation,
- The crew was continuously distracted during the flight,
- Lack of technical documentation in the CIA that supports the operation,
- Lack of crew training about Crew Resources Management, human factors and Control Flight Into Terrain(CFIT),
- The weather conditions at the time of the accident on Mt El Tigre made it impossible for the crew to see the mountain,
- The aircraft was not equipped with a Ground Proximity Warning System (GPWS).

The crew suffered a loss of situational awareness after takeoff while climbing in IMC conditions. The crew failed to comply with the Girardot 1 departure procedure, deviated from the published departure procedures and maintain runway heading until the aircraft collided with terrain.