Brazil

The accident was the consequence of a poor approach planning and wrong approach configuration.
The following contributing factors were reported:
- Deficiencies in crew training,
- Deficiencies in flight controls,
- Poor crew coordination,
- Poor judgment,
- Poor planning,
- Lack of supervision.

A. Human Factor
1) Physiological aspect - Did not contribute to the accident.
2) Psychological aspect - The following psychological variables contributed to the accident:
a) Misleading perception - In the reading of the plan and incorrect heading insertion by the commander.
b) Reinforcement - In the reading and incorrect heading insertion by the co-pilot and heading conference placed by the commander.
c) Marginal attention and level of attention - The non-recognition of conditions that would mean being far from the objective: request for "VHF bridge" when other aircraft were talking normally with the Control; "reception" of commercial stations, and non-receipt of destination NDB, etc.
d) Predisposition - Maintaining the urge to go to the established objective (Belém).
e) Predisposition duration - Maintenance of FL040 for a long time.
f) Reinforcement of predisposition - Reception of boundaries when selecting Belem's radio frequencies.
g) Attention Fixing - Permanent search for headings, radio contacts or river contours, as an alternative, to reach the fixed goal.
h) Blocks - Delays in identifying the initial headings error and plotting itself in navigation.
i) Geographical position error.
B. Material Factor - Did not contribute to the accident.
C. Operational Factor
1) Poor supervision - Inadequate graphical representation of the Computer Flight Plan.
2) Poor cockpit coordination - No supervision of cockpit activities. Actions were not supervised, but imitated.
3) Poor support staff - Lack of radio contact by the operator's Flight Coordination with the aircraft in flight, after the significant landing delay in Belém, thus breaking the chain of events of the accident.
4) Pilot aspect characterized by environmental influence - Difficulties of visualization due to sunset and dry fog: Radio aid markings received from great distances, originating from the ionospheric propagation of electromagnetic waves.
5) Pilot aspect characterized by poor planning - Lack of route letters to cross the flight plan information.
6) Pilot aspect characterized by poor judgment - Inadequate evaluation and use of radio-navigation equipment, resulting in the pursuit of markings without causing tuning and identification.
7) Pilot aspect characterized by other operational factors - Operational doctrine firming.

It is believed that the loss of control may have been the result of windshear that existed in the approach path of runway 06.
The following contributing factors were reported:
- The crew did not have sufficient training and experience to manage a windshear situation and thus, was unable to take the appropriate corrective actions,
- Poor crew coordination,
- The captain's experience on this type of aircraft was low,
- Poor supervision,
- Lack of safety culture by the operator.

The accident was the consequence of the combination of the following factors (findings):
- The imminent interruption of operations in the aerodrome that would be used for landing the aircraft (closure of runway 09R due to works) stimulated the instructor to make a hurried descent, characterizing a potential state of anxiety,
- Probable crew fatigue,
- The instruction given to the pilot was discontinued and the local flight did not comply with the minima provided in RAC 3211,
- The failures found in the instruction were due to poor supervision of the Company's operations sector,
- Poor crew coordination,
- During the descent procedure when working checklist, the instructor broke the sequence of standardized procedures, thus stopping the instruction and consequently, the student's core handling of the flight,
- The instructor, without the student being informed beforehand, commanded the flaps together with the speed brakes. This action configured an abnormal attitude that contributed, without the pilots identifying, to the loss of control of the aircraft,
- The flight engineer also failed to meet the checklist items,
- The instructor did not follow the standardization of the instruction, when he executed a decision in a hurry,
- The crew did not respond to the sinking and pull up warnings,
- Error in the application of flight controls,
- The crew did not operate in accordance with the operational standard issued by the manufacturer and endorsed by the company,
- The air traffic controller contributed to the increase of the crew anxiety level by using non standard phraseology.