Brazil

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.

The following findings were identified:
- The total weight of the aircraft upon departure from Belém Airport was 650 kilos above MTOW,
- The cargo was not stowed in the cabin but simply stored on the floor,
- The left engine was not providing power at impact and the aircraft entered a left turn and then an uncontrolled descent until impact with the ground,
- Failure of the left engine due to the presence of an aluminum part obstructing the fuel pipe. Metallographic analyzes confirmed that this aluminum part likely came from a thread of the fuel pump,
- Complacency of the crew who failed to follow the published procedures of the operator.

Failure of both engines in flight due to fuel exhaustion. The following findings were identified:
- The crew failed to prepare the flight according to published procedures,
- The crew failed to check there was sufficient fuel in tanks prior to departure,
- The crew failed to follow the pre takeoff checklist,
- The captain showed excessive self confidence
- The captain exercised pressure on the copilot,
- The crew suffered fatigue due to an excessive period of work. At the time of the accident, the crew was overduty by three hours,
- The crew consumed alcohol beverages the night before the flight.

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.

It is believed that the engine fire was the consequence of the failure of a fuel burner.

The following findings were identified:
- The exact cause of the left engine failure and fire remains unknown,
- The pilot was not qualified to fly such type of aircraft,
- The aircraft was not airworthy at the time of the accident,
- The aircraft maintenance was not performed according to published procedures.

The following findings were identified:
- There was the participation of factors, with their own characteristics, that caused failures of attention, judgment and perceptual evaluation of distances and temporality. The qualitative training deficiency, the lack of cabin resource management and the low situational alert were significant contributing factors to the accident.
- PF has performed poorly in the use of the correct piloting technique in the combination of Speed x Ratio of Descent parameters.
- The instructor assigned by the company to supervise the acquisition of operational experience on route had not received specific instruction for the performance of this task. Technical and operational supervision was lacking.
- PF had good flight experience, but not in this type of aircraft. It was in the phase of acquiring operational experience in route. The inadequate action was also due to the little experience in the aircraft and in the circumstance of the operation, which required a quick correction close to the ground.
- The pilots did not adequately utilize the resources available in the cockpit for the proper operation of the aircraft. PF did not make the necessary corrections to modify the aircraft's trajectory, which was its assignment. The instructor (PNF), in turn, did not effectively correct or interfere with the PF flight, which would have been his responsibility since he was the supervisor of the operation. The pilots did not observe, yet, the technical-operational procedure foreseen in the Flight Operations Manual (MOV), regarding the GPWS warning. The crew did not observe that the warning determined an unsafe condition close to the touch. It was characterized an ineffective fulfillment of the tasks assigned to each crew member, besides the non-observance of the operational rules.
- On the IMC approach made, the PF varied the parameters, remaining high on the ramp. Upon reaching visual conditions, the PF increased the descent rate of the aircraft. The PNF, concerned with locating the runway, did not consider an inadequate PF correction.
- The PF, with the intention of reducing the drop ratio, did not apply correctly, in amplitude and in time, the power available in the engines. Near the touch, the PF increased the pitch angle, trying to reduce the drop ratio. Considering the low height (approximately 80 ft) and engine power (IDLE), the aircraft continued with a high rate of descent (approximately 1,800 ft/min), without the action taken by the PF altering its path. The PNF did not interfere in the application of the commands. Therefore, there was inadequate use of the aircraft commands by the crew members, in conditions for which they were qualified.
- The PF, even being alerted by the PNF about the low speed and high rate of descent, thought it was applying an adequate correction, however it kept the aircraft in an incompatible performance for landing. The PNF, despite having experience in flight and in the aircraft, showed a lack of knowledge of its limits regarding the point of irreversibility of an unsafe situation. The PNF was limited to alerting the PF about the situation, not guiding it on the correct way to make the corrections.
The PNF overestimated PF's capacity and did not take or try to take over the controls.
- The pilots were not aware of the maximum rate of descent during the touch for which the aircraft was certified, nor were they aware of the variation of that rate with respect to weight. The availability of the autopilot to the MDA could have minimized the ramp deviation observed.

The following findings were identified:
- There was the participation of psychological variables at individual level, related to the profile of the pilot, such as excessive self-confidence in assuming that he always reached his destination, the knowledge of the region and probably the self-induced pressures by the situation in the cabin, combined with the prevailing meteorological condition, as well as the fact that he made a mistake with the procedure he was performing, demonstrating the adoption of an inadequate decision, excessive motivation for landing and lack of attention to the correct procedure.
- It was not possible to perform an effective analysis on the parts and instruments of the aircraft, in view of their degree of destruction, thus the contribution of this factor to the accident could not be determined.
- Weather conditions at destination were fickle and deteriorated during the execution of the descent procedure of the aircraft, contributing to the accident.
- The pilot failed to comply with the planned descent profile in use.
- Despite being aware of the meteorological conditions at destination, the pilot did not adequately plan the accomplishment of the procedure of descent by instruments, coming to throw out of the established profile, suggesting that he did not undertake the briefing of descent.
- The performance of the procedure outside the foreseen profile and in instrument flight conditions, determine the participation of this aspect in the occurrence.