Ribeirão Preto

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.

Contributing Factors:
- There was the participation of individual psychological variables in the pilot-in-command's performance due to the excess of self-confidence and self-demand in his customary behavior, besides the dissimulation regarding his real qualification for the type of flight. The personality with traces of permissiveness and insecurity of the co-pilot also contributed to the occurrence, as it allowed the aircraft to be operated by an unqualified pilot, with no employment link with the company.
- There was a lack of adequate supervision by Manacá Táxi Aéreo, as it allowed a crew member who had not operated the type of aircraft for one year and had not made any type of flight for four months, besides not having any employment relationship with that company. It is also necessary to consider the failure of supervision at the organizational level due to the issue of an incorrect license by the DAC, giving rise to the possibility of its use for the revalidation of license in aircraft for which the pilot was not qualified to exercise the function of commander.
- The entire sequence of events began with pilot errors resulting from the pilot's lack of flight experience in the left-hand seat on the aircraft in question.
- The inadequate use of cockpit resources destined to the aircraft operation, due to an ineffective accomplishment of the tasks assigned to each crew member, besides the interpersonal conflict resulting from the co-pilot's intervention in the pilot in command operation, in the final approach phase, already close to the aircraft's touchdown, configure the collaboration of this factor to the accident.
- The inadequate use of the aircraft commands, by the pilot in command, making excessive aileron corrections in the final approach phase, near the landing.
- The pilot was qualified as a co-pilot on the equipment, but due to a typing error, he was issued a pilot license. Thus, the situation and operation of the pilot in question were totally irregular.

The following findings were identified:
- The crew was in a hurry to take off in order to avoid poor weather approaching the airport,
- The crew took off from an intersection with a taxiway,
- Immediately after takeoff, the aircraft entered clouds,
- Approximately one minute after liftoff, the aircraft impacted ground,
- After the first impact, the aircraft flew for another 200 metres and again collided with the ground and exploded,
- The aircraft was totally destroyed by a post crash fire,
- The pilot had a hearing problem that was stabilized and was being researched by HASP. Considering the relationship between ear and ear balance, spatial disorientation in the pilot in
in the face of the adverse conditions it experienced: flight conditions by instruments associated with “windshear”. Since the search could not be completed above mentioned, this aspect remains undetermined,
- Individual characteristics contributed due to the habits acquired by the pilot and his eventual practice of taking off from the taxiway, delaying the point from which the aircraft would achieve the best characteristics flight performance,
- Poor weather conditions with CB's, sudden changes in wind, strong turbulence and rain, were conducive to the emergence of the phenomenon of “Windshear”, representing a real risk to the operation of any aircraft, being that voluntary entry or not, in this type of training, results almost always in the loss of control of the aircraft with unforeseeable consequences. The crew faced these conditions when the aircraft took off,
- It was evident from the witness statements that the pilot was in a hurry to take off, in addition to having used runway 23 from the intersection and towards the sector most affected by poor weather.

The following findings were reported:
- There are indications of the presence of psychological variables that may have influenced the instructor's decision to perform the touch-and-go manoeuvre.
- There was inadequate supervision, at the technical and operational level, by the aircraft operating company, due to the lack of training, inadequate instruction and absence of flight simulator training.
- There was an error made by the pilots due to the inadequate use of the crew resources in the cockpit intended for the operation of the aircraft, due to an ineffective fulfillment of the tasks assigned to each of the crew and the non-observance of the operational rules.
- Even though the crew was qualified for the type of flight, there was inadequate planning regarding the absence of a takeoff and landing briefing.
- There was an error made by the copilot, when the delay in reducing the power levers, as soon as the locking of the left engine lever was established during the dash on the ground, with an inadequate assessment of the situation in this regard.
- There was the participation of the training process received, due to quantitative and qualitative deficiency, which did not attribute to pilots the full technical conditions to be developed in the activity, regarding the lack of simulator training, lack of a company training program that included CRM and local flights, among others.
- There are indications that the difficulties reported by the pilots in relation to the throttle were caused by the rupture of fibers in the cable that transfers its control to the FCU. This cable slides inside a corrugated cover and can be jammed if any fiber in the cable breaks.

It appears that the left engine failed shortly after rotation and that a fuel line ruptured. Fuel leaked in the engine nacelle and caught fire while contacting high temperature engine components.

Engine failure.