Brazil

Following a wrong approach configuration on part of the crew, it was determined that the airplane landed about 600 metres from the runway end. In such conditions, the airplane could not be stopped within the remaining distance.
The following contributing factors were identified:
- Both pilots knew each other well and often flew together, thus it is possible that they over-relied on each other during the final phase of the flight,
- This over-confidence led the crew to neglect certain parameters related to the approach manoeuvre,
- Lack of crew coordination,
- Post-accident medical examinations revealed that the pilot-in-commands' (PF) lack of reaction to the pilot monitoring's (PM) warnings, and his impaired alertness, could indicate that he was suffering from the effects of alcohol and fatigue, reducing his performances,
- The pilots' decision to continue with the landing procedure despite an unstabilized approach characterized by inadequate situational awareness,
- Poor judgment on the part of the crew who failed to take the correct decision to initiate a go-around procedure.

Studies and research showed that the low deceleration of the aircraft and the limitation of the hydraulic pressure provided by the brake system were compatible with a slippery runway scenario. Thus, one inferred that the runway was contaminated, a condition that would reduce its coefficient of friction and impair the aircraft's braking performance, making it impossible to stop within the runway limits. On account of the mirroring condition of the runway in SSDK, it is possible that the crew had some difficulty perceiving, analyzing, choosing alternatives, and acting appropriately, given a possible inadequate judgment of the aircraft's landing performance on contaminated runways.

One should not rule out the hypothesis of a possible malfunction of the aircraft's angle-of-attack control system, considering that the records related to the provision of the calibration service (a necessary condition for the proper functioning of the referred system, and prescribed in the aircraft's maintenance manual) were not identified in the pertinent
control documents.

The exact cause of the accident could not be determined. However, it is believed that the pilot may have encountered an unexpected situation that he was unable to manage due to his relative low experience.

The accident was the consequence of the combination of the following factors:
- Attention – undetermined.
It is likely that the pilot has experienced a lowering of his attention in relation to the available information and the stimuli of that operational context in face of the adverse conditions faced.
- Attitude – a contributor.
It was concluded that there was no reaction to the warnings of proximity to the ground (Caution Terrain) and evasive action to avoid collision (Pull Up), a fact that revealed difficulties in thinking and acting in the face of an imminent collision condition, in which the aircraft was found.
- Adverse meteorological conditions – a contributor.
The clouds height and visibility conditions did not allow the flight to be conducted, up to SBMT, under VFR rules.
- Piloting judgment – a contributor.
The attempt to continue with the visual flight, without the minimum conditions for such, revealed an inadequate assessment, by the pilot, of parameters related to the operation of the aircraft, even though he was qualified to operate it.
- Perception – a contributor
The ability to recognize and project hazards related to continuing flight under visual rules, in marginal ceiling conditions and forward visibility, was impaired, resulting in reduced pilot situational awareness, probable geographic disorientation, and the phenomenon known as " tunnel vision''.
- Decision-making process – a contributor.
The impairment of the pilot's perception in relation to the risks related to the continuation of the flight in marginal safety conditions negatively affected his ability to perceive, analyze, choose alternatives and act appropriately due to inadequate judgments and the apparent fixation on keeping the flight under visual rules, which also contributed to this occurrence.

Contributing factors.
- Control skills – a contributor
The inadequate performance of the controls led the aircraft to make a ramp that was lower than the ideal. This condition had the consequence of touching the ground before the runway’s threshold.
- Attention – undetermined
During the approach for landing, the commander divided his attention between the supervision of the copilot's activities and the performance of the aircraft's controls. Such circumstances may have impaired the flight management and limited the reaction time to correct the approach ramp.
- Attitude – undetermined
The report that the commander took two photographs of the runway and of the Aerodrome with his cell phone, during the wind leg, reflected an inadequate and complacent posture in relation to his primary tasks at that stage of the flight, which may have contributed to this occurrence.
- Communication – undetermined
As reported by the commander, the low tone and intensity of voice used by the copilot during the conduct of callouts, associated with the lack of use of the head phones, limited his ability to receive information, which may have affected his performance in management of the flight.
- Crew Resource Management – a contributor
The lack of proper use of CRM techniques, through the management of tasks on board, compromised the use of human resources available for the operation of the aircraft, to the point of preventing the adoption of an attitude (go-around procedure) that would avoid the accident, from the moment when the recommended parameters for a stabilized VFR approach are no longer present.
- Illusions – undetermined
It is possible that the width of the runway, narrower than the normal for the pilots involved in the accident, caused the illusion that the aircraft was higher than expected, for that distance from the thrashold 11 of SIRI, to the point of influence the judgment of the approach ramp. In addition, the fact that the pilot was surprised by the geography of the terrain (existence of dunes) and the coloring of the runway (asphalt and concrete), may have led to a false visual interpretation, which reflected in the evaluation of the parameters related to the approach ramp.
- Piloting judgment – a contributor
The commander's inadequate assessment of the aircraft's position in relation to the final approach ramp and landing runway contributed to the aircraft touching the ground before the thrashold.
- Perception – undetermined
It is possible that a decrease in the crew's situational awareness level resulted in a delayed perception that the approach to landing was destabilized and made it impossible to correct the flight parameters in a timely manner to avoid touching the ground before the runway.
- Flight planning – undetermined
It is possible that, during the preparation work for the flight, the pilots did not take into account the impossibility of using the perception and alarm system of proximity to the ground that equipped the aircraft, and the inexistence of a visual indicator system of approach ramp at the Aerodrome.
- Other / Physical sensory limitations – undetermined
The impairment of the hearing ability of the aircraft commander, coupled with the lack of the use of head phones, may have interfered with the internal communication of the flight cabin, in the critical phase of the flight.

The accident was the consequence of the combination of the following factors:
- Control skills – undetermined.
While facing adverse conditions, the use of controls may have been inappropriate for the situation and may have contributed to the aircraft not being able to maintain a positive climb rate.
- Attitude – undetermined.
Familiarization with the region may have led to an attitude, on the part of the PIC, of minimizing the importance of analyzing adverse weather conditions, to the detriment of compliance with the minimum limits established by the company in its manuals.
- Training – undetermined.
It is possible that, due to possible inadequate training, the SIC did not identify the critical situation that arose shortly after the take-off in time to assist the PIC in maintaining flight control.
- Tasks characteristics – undetermined.
The characteristics present in the type of operation, compliance with schedules without the possibility of delays, due to the runway closing period, may have favored the self imposed pressure on the part of the PIC, leading him to operate with reduced safety margins.
- Adverse meteorological conditions – a contributor.
The conditions at the time of the take-off contributed to the aircraft not being able to maintain the flight with a positive climb rate. The probable occurrence of Windshear determined that the trajectory of the aircraft was modified until its collision with the ground.
- Crew Resource Management – undetermined.
On the part of the SIC, no assertive attitude was perceived in the sense of alerting the PIC that those conditions were not favorable for takeoff. Thus, the crew decided to carry out the take-off despite the company's SOP.
- Organizational culture – undetermined.
The company encouraged compliance with the legs even though, within the planning of flights, there was not an adequate margin of time to absorb any delays. This culture may have influenced the PIC's decision-making, which, despite encountering adverse conditions, chose to take off, since the short time on the ground in the intermediate locations did not allow room for delays.
- Emotional state – undetermined.
The reports indicated that the PIC felt pressured to perform the take-off even in the weather conditions found on the day of this occurrence. Also, according to the interviewees, this pressure would be related to the fulfillment of the flight schedule and the need to keep to the scheduled times. In this way, it is possible that their assessment of the performance of the flight was influenced by the stress resulting from the pressure to complete the flight within the expected time, given the closing time of the runway for works.
- Flight planning – a contributor.
The flight planning was not carried out properly, considering that the planned schedules and routes would end after the closing time of the SBEG runway for works, provided for in the NOTAM. This meant that there was little time to adjust the legs, increasing the workload and stress in the cabin.
- Decision-making process – a contributor.
There was a wrong assessment of the meteorological conditions, which contributed to the decision of performing it in an adverse situation.
- ATS publication– undetermined.
The TWR-EG did not inform, before the take-off, of the changes in the significant weather conditions that were occurring at the terminal, which could have contributed to the PIC's decision-making.

The following findings were identified:
- Attention,
- Judgment,
- Perception,
- Management planning,
- Decision making processes,
- Organization processes,
- Support systems.