Brazil

The following findings were reported:
- Possible crew fatigue that diminished their performances,
- Possible psychological and organizational diminution,
- Possible inadequate supervision of the operator in flight planning, and non-compliance with procedures in force,
- Following a lack of crew resources management, the crew failed to follow the standard descent procedures,
- Poor approach planning on part of the crew,
- It is possible that the crew did not observe sufficient rest time,
- It is also possible that there was an intentional disobedience by the crew of ATC rules and operational standards, in relation to the use of the GPS equipment during the descent, even though this was not approved for such procedure.

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.

The following findings were reported:
- The crew was tired due to a long duty period of 16 hours and 30 minutes without rest time,
- The captain showed excess of self-confidence,
- Physical fatigue worsened the level of situational stress of the crew,
- Lack of crew training programme,
- Poor crew coordination,
- Poor approach and landing planning,
- Lack of visibility, lack of ground lights (environment) and low clouds,
- The crew failed to follow the missed approach procedures,
- The copilot was inexperienced,
- Instead of a right turn to 092° and continue to 6,000 feet, the captain initiated a left turn, causing the aircraft to struck obstacles.

The following findings were reported:
- There was overconfidence, coupled with an impulsive attitude on the part of the instructor, making him convinced that he could land without problems, even changing the procedure already established and not communicating his decision to the copilot/student.
- The instructor did not properly plan the landing procedure that he decided to carry out, contrary to the briefing.
- There was an error in the instructor's judgment, due to the inadequate assessment of normal landing with 15º flap configuration and speed about 10kt above the predicted, contrary to previous briefing.
- The instructor did not inform the student of his decision to complete the landing, without rush, as well as not responding to the request to start the rush. The student accelerated the engines without the instructor's authorization.

The following factors were reported:
- The flight schedule to which the crew members were being subjected at the time they were operating in the company was contrary to Law 7.183 of 1984 and may have led them to chronic fatigue and stress conditions.
- There are indications that psychological variables at the organizational level, with respect to flight scale, training, standardization and procedures of the company and the flight group contributed to the accident.
- Throughout the operation, both crew members showed signs of anxiety, complacency, underestimation regarding the information received, motivation, change in perceptual synthesis, illusion and inattention.
- The cloud base and visibility conditions made it difficult to navigate and identify the control points on the ground, as well as making it impossible to see the obstacles.
- Insufficient planning has led to crew members failing to navigate and fly themselves.
- The failure of the crew to judge in relation to continued flight in adverse weather conditions and below the limits set by the Rules of the Air (IMA 100-12) contributed to the accident.
- There is evidence of the company's involvement in the investigation process, which did not give the crew the full technical conditions necessary for the flight to take place.
- The failures committed on this flight indicate that at least one crew member failed to use the available navigation resources and the other failed to advise.
- There was an influence of the visibility and ceiling conditions, as well as the physical environment, in relation to the similarity between the valleys of the Itajaí River and Itajaí Mirim. There is also evidence that conditions in the administrative-operational environment of the company and the group of pilots contributed to the difficulties the pilots faced.
- The errors found imply failures of supervision in the flight schedule sector, with regard to compliance with the law, training and operations sector.
- The crew had little experience as pilots in the company and on the route flown.

The following contributing factors were reported:
- The traffic and the high number of landings caused a natural fatigue by the instructor and reduced his appreciations,
- There were too much pilots under training for one single instructor,
- The copilot's experience was insufficient with only one hour on Cessna 208,
- Poor crew coordination,
- Poor crew action on engine power to expect recovery after stall.