Brazil

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.

Loss of control after the crew encountered adverse weather conditions with low level windshear. The following contributing factors were identified:
- Although the operations were carried out in accordance with the regulations in force, the pilots regularly exceeded the flight times and this type of prospecting mission is extremely tiring insofar as it is systematically operated at low altitude without the aid of the autopilot system in a high outside temperature environment, leading to greater than normal physical wear of the pilots,
- Poor flight preparation regarding the probable evolution of the weather conditions,
- The accident occurred in low visibility as the crew was presumably trying to return to his base,
- The accident occurred outside of the intended flight area,
- The flight, which was scheduled to take three hours, was started with an aircraft whose tanks were full (seven hours autonomy), unnecessarily increasing its weight,
- Poor flight planning,
- Non-compliance with standard operator procedures on part of the crew who positioned the flaps in an inappropriate angle to fly over obstacles,
- In the days preceding the accident, two incidents occurred at Paramirim Airport involving the captain, and neither of these two events had been reported to the management of the operator, indicating the absence of an effective control of operations,
- The supervision of crew schedules was poor,
- The operator wanted this type of flight to be carried out in the morning in order to avoid atmospheric turbulence specific to the region, but the crew decided to take off in the afternoon when the conditions were not favorable.

The crew continued the descent under VFR mode in IMC conditions and descended too low to maintain a visual contact with the ground until the aircraft impacted terrain. The following contributing factors were identified:
- Poor crew coordination,
- Lack of visibility,
- The crew failed to follow the published procedures.

The following findings were identified:
- It was not possible to determine the contribution of the physiological aspect because the pilot was not found and his license had expired.
- At the critical moment of landing, a state of indecision was triggered in the pilot regarding the procedure to be adopted (landing or going around), impairing its decision-making capacity and causing delay in decision making.
- The pilot did not act adequately on the aircraft controls in order to counteract the action of the crosswind, allowing the aircraft to stand to the right of the approach axis and touch the right side of the runway. Subsequently, he was unable to prevent the left wings from climbing, causing the lower right wing to touch the ground and exit the runway.
- The pilot's decision not to go around immediately when he noticed the first signs of the aircraft's turning tendency, forced by the wind effect and, consequently, having lost full control of the aircraft, contributed to the worsening of the subsequent facts. The pilot acted belatedly when he decided to go around.
- The owner of the aircraft no longer verified that the technical qualification and the Certificate of Physical Capacity of the pilot were up to date for the performance of the air activity, as well as the certificates necessary for the operation of the aircraft. It also went against what prescribes the CTA certification, which establishes two pilots as the minimum crew for the aircraft.
- The left cross wind, associated with the inadequacy of the pilot's controls to counteract it, resulted in the right wing touching the ground, with consequent loss of control of the aircraft.
- The pilot failed to carry out a readaptation flight in the aircraft with a qualified instructor, being for more than three years without flying in the equipment.

The accident occurred in poor weather conditions. It was determined that during initial climb, the aircraft's attitude, speed and altitude varied suddenly and rapidly, causing the pilot flying a stressful situation insofar as he believed that artificial horizons presented technical problems. In such a situation, investigators consider probable the hypothesis that the pilot made inadequate corrections, exacerbating the abnormal situation in which he was operating. The following contributing factors were identified:
- The crew were suffered fatigue because they had been on duty for more than 15 hours and were unable to observe satisfactory rest time at Congonhas airport,
- This fatigue certainly affected the pilots in their decision-making,
- The urge to return home and distrust of instruments in difficult flight conditions seriously compromised the performance of pilots and their ability to make decisions,
- A direct contact with passengers was stressful as they were going through a period of mourning and were eager to return home to Maringá,
- Weather conditions were unfavorable and contributed to the anxiety of the crew,
- Poor assessment of these conditions by the pilots,
- The working time of the pilots exceeded the limitations and the operator did not take into account adequate rest conditions for the crew,
- The training of the captain in instrument flights in recent months was insufficient.

Both engines failed 12 minutes apart due to fuel exhaustion. The following contributing factors were identified:
- Fuel tanks were empty,
- The fuel quantity was insufficient to cover the requested flying distance,
- Poor flight preparation and planning,
- Complacency on part of the copilot,
- Wrong decisions on part of the captain,
- Failures in the organization of flights within the operations of the Government of the State of Goiás,
- Miscalculations in fuel consumption.
- Operating an airplane with faulty fuel gauges,
- Failures in monitoring related to flight safety culture,
- Poor crew resources management,
- Poor crew coordination,
- Lack of crew interactions.

Failure of the left engine that was not lubricated according to published procedures. Inappropriate engine maintenance on part of the operator. Also, it was reported that the pilot's experience on this type of aircraft was insufficient.

The aircraft suffered aquaplaning after landing and was unable to stop within the remaining distance. The following contributing factors were identified:
- The operator authorized the crew to divert to an unapproved airport with an aircraft weighing more than the limits specified in the operations manual without performing adequate supervision in the execution of the flight;
- Deviations on part of the crew;
- Lack of Crew Resources Management;
- Lack of crew coordination and communication;
- Lack of crew instruction and training on part of the operator;
- Poor weather conditions with heavy rain falls;
- The runway surface was wet and the aircraft suffered aquaplaning;
- The aircraft was overloaded;
- The landing was completed with a tailwind component;
- The crew failed to perform the approach briefing according to published procedures.

Engine failure due to poor maintenance. The following contributing factors were identified:
- Maintenance procedures not followed by the operator mechanics,
- Poor crew coordination,
- Lack of crew training.

Double engine failure on final approach due to fuel exhaustion. The following contributing factors were identified:
- Poor flight preparation and planning,
- The crew was overconfident,
- The crew miscalculated the total fuel quantity needed for the entire mission,
- Wrong fuel consumption calculation,
- Taxing time and wind component were not taken into consideration in the fuel consumption calculation,
- Incorrect values relative to the aircraft performances,
- Poor crew resources management.