Brazil

Contributing factors:
- Attention - undetermined
Moments before the accident, another aircraft successfully completed the landing at the Paraty aerodrome. It is possible that the pilot's attention was focused on this information, which indicated the possibility of landing, despite the critical conditions faced, leading him to take high risks to make the landing in critical conditions.
Also, the presence of a copilot not qualified to operate the aircraft may have influenced the pilot's cognitive processes, causing deconcentration or deviation of attention from the pilot.
- Attitude - contributed
Recurring attempts to make the landing indicated an excess of self-confidence on the part of the pilot, leading him to continue the flight to the Paraty aerodrome, even in adverse weather conditions.
The bold operational profile of the pilot, his past experience and the rules and values ​​adopted informally in the group of pilots are possible factors that influenced the development of this attitude of excessive self-confidence.
- Adverse weather conditions - contributed
On the day of the accident, the weather conditions were not favorable for visual flight at the Paraty aerodrome.
- Culture of the working group - contributed
Among the pilots who operated in the Paraty region, competitive behavior had been installed, valued by the social recognition attributed to those who managed to operate in critical conditions. Above all, landing under conditions adverse weather conditions in the region was considered a manifestation of proficiency and professional competence. The values ​​shared by that group of pilots favored the weakening of the collective perception about the present operational risks. The presence of other pilots who were also trying to land in the region on the day of the occurrence, as well as the landing made by one of these aircraft, moments before the accident, and also the accomplishment of two failed attempts of the PP-LMM aircraft, translates clear evidence of that behavior.
- Pilot forgetfulness - undetermined
The fact that the landing gear was not retracted during the second launch in the air indicated a failure, fueled by the possible forgetfulness of the crew, to perform the planned procedure. Maintaining the landing gear in the lowered position affected the aircraft's performance during the ascent, which may have contributed to the aircraft not reaching the height required to clear obstacles.
- Pilotage Judgment - undetermined
The possible decision not to retract the landing gear during the launch affected the aircraft's performance during the climb, which may have contributed to the aircraft not reaching the height necessary to clear the obstacles.
- Motivation - undetermined
The successful landing by the pilot of another aircraft, even under unfavorable conditions, may have increased the motivation of the pilot of the PP-LMM aircraft to complete the landing, in order to demonstrate his proficiency and professional competence.
- Perception - contributed
The occurrence of a collision with the ground, in controlled flight, indicated that the crew had a low level of situational awareness at the time of the occurrence. This inaccurate perception of the circumstances of the flight made it impossible to adopt the possible measures that could prevent the collision.
- Decision making process - contributed
The pilot chose to make two landing attempts at the Paraty aerodrome, despite adverse weather conditions, indicating an inaccurate assessment of the risks involved in the operation. This evaluation process may have been adversely affected by the competition behavior installed among the pilots. In this context, it is possible that the pilot based his decision only on the successful landing of another aircraft, a fact that limited his scope of evaluation.
- Organizational processes - undetermined
The PP-LMM aircraft was operated by a group of pilots, mostly composed of freelance professionals, who were informally managed by a hired pilot. Therefore, there was no formal system used by the operator to recruit, select, monitor and evaluate the performance of professionals. The failures related to the management of this process, possibly, caused inadequacies in the selection of pilots, in the crew scale, in untimely activations and, as in the case in question, in the choice of crew member not qualified to exercise function on board.

Contributing factors:
- Control skills – undetermined
It is possible that, after inadvertent movement of the horizontal stabilizer, the crewmembers did not operate on the control switches of the secondary pitch trim system, since no other warning sound (Clacker) was recorded on the CVR recordings. The action prevised in the emergency procedures Pitch Trim Runaway or Failure, item 3, regarding trimming of the aircraft through the secondary system, possibly, was not performed. The performance of the crew may have been restricted only to the elevator control on the aircraft controls or to the control of the stabilizer associated with the primary trimming mode.
- Attitude – undetermined
The decision to make the flight without the proper functioning of the primary pitch trim and autopilot system may have been the result of the pilot's self-confidence because of the successful previous flight under similar operating conditions. Considering the hypothesis that the updated Shutdown Checklist, which should incorporate the Stabilizer Trim Backdrive Monitor - TEST, was not performed after the precrash flight, one could consider that there was a lack of adhesion to the aircraft operating procedures. Such an attitude could be associated with the pilot's self-confidence about the aircraft's operating routine, whose acquired experience could have given him the habit of ignoring some of the procedures deemed less important during the flight completion phase.
- Crew Resource Management – a contributor
Throughout the flight, there was an absence of verbalization and communication of the actions on the checklist. Similarly, in the face of the emergency situation of the horizontal stabilizer (Pitch Trim Runaway or Failure), no statements were identified regarding the actions required to manage this situation among the crew. These characteristics denote inefficiency in the use of human resources available for the aircraft operation.
- Training – undetermined
It is possible that the absence of a periodic training in simulator, especially the emergency Pitch Trim Runway or Failure, has affected the performance of the crew, as far as the CVR did not record statements related to the actions required by the abnormal condition experienced.
- Organizational culture – undetermined
The operator did not usually properly fill out the PT-WQH flight logbook. This condition evidenced the existence of informal rules regarding the monitoring of the operational conditions of the aircraft. In this context, it is possible that the history of failures related to the pitch trim system has not been registered.
- Piloting judgment – undetermined
Moments prior to takeoff, it was recorded in the CVR speeches related to the flight without the autopilot, possibly related to a failure or inoperativeness of the primary pitch trim system. The takeoff with a possible failure in the pitch trim system of the aircraft, showed an inadequate assessment of the risks involved in the operation under those conditions.
- Aircraft maintenance – undetermined
It was not possible to establish a link between the maintenance services performed on the aircraft in September 2015 and the events that resulted in the accident occurred on 10NOV2015. However, it was not ruled out that an incomplete crash survey was carried out in the pitch trim system of the aircraft, due to the lack of detail of the service orders.
- Decision-making process – a contributor
The sounds related to the test positions of the Rotary Test Switch have not been recorded in the CVR recording, so it is possible to conclude that the Warning Systems - Check item of the Cockpit Preparation Checklist has not been performed. The decision to perform the flight without the complete execution of all items of the Cockpit Preparation Checklist, prevented the correct verification of the primary longitudinal Trim system of the aircraft and reflected an inadequate judgment about the risks involved in that operation.
- Interpersonal relationship – undetermined
According to the CVR data, there was a possible rush of the crew to take-off, even though it was verified that the aircraft's pitch trim system did not work properly. It was not possible to determine if this rush was motivated by passengers’ pressure or self-imposed by the pilot.
- Support systems – undetermined
It is possible that the Pilots' Abbreviated Checklist - NORMAL PROCEDURES, aboard the aircraft, was outdated, without the incorporation of the Stabilizer Trim Backdrive Monitor - TEST procedure in the Shutdown Checklist. The possible completion of Shutdown Checklist with outdated procedures would have hampered the manufacturer's suggested verification for identification of abnormalities in the aircraft's pitch trim system.
- Managerial oversight – undetermined
The records and control of the operational check flights, both by the maintenance shop and by the operator, prevised in documentation issued by the manufacturer (SB650- 27-53 and ASL650-55-04) were not performed in an adequate manner, indicating possible weaknesses in the supervision of the maintenance activities.

It is believed that the accident was a consequence of a wrong takeoff configuration as the crew did not set the flaps properly.

Loss of control after the crew initiated aerobatic maneuvers at low altitude.

Failure of the left engine in flight due to fuel exhaustion. The following findings were identified:
- The fuel tanks in the left wing were empty while a quantity of 320 litres of fuel was still present in the fuel tanks of the right wing,
- The crew was unable to maintain altitude because he could not feather the left propeller,
- The pilots were misled by a false indication of the fuel gauge coupled to the left wing tank which displayed a certain value while the tank was actually empty. This error was caused by the fuel sensors for the left wing tanks being installed inverted,
- The aircraft was not airworthy at the time of the accident due to several defects,
- The Minimum Equipment List (MEL) was not up to date,
- The Cockpit Voice Recorder (CVR) was unserviceable,
- The automatic propeller feathering system was out of service,
- The fuel sensors for the left wing tanks had been installed inverted,
- Bad contact with the right wing fuel sensor connector plug,
- The pilots failed to follow the published procedures related to an engine failure,
- Poor flight preparation,
- Crew complacency,
- The crew training program by the operator was inadequate,
- Lack of supervision on part of the operator.

The following factors were identified:
- Considering the pronounced angle formed between the trajectory of the aircraft and the terrain, as well as the calculated speed (which by far exceeded the aircraft operating limit) moments before the impact, it is possible to infer that, from the moment the aircraft disappeared in the clouds, it could only have reached such speed and flown that trajectory if it had climbed considerably, to the point of being detected by the radar. Such condition presented by the aircraft may have been the result of an exaggerated application of controls.
- The making of an approach with a profile different from the one prescribed shows lack of adherence to procedures, which, in this case, may have been influenced by the self-confidence of the pilot on his piloting ability, given his prior experiences.
- Despite the lack of pressure on the part of the passengers to force compliance with the agenda, it is a known fact that this type of routine creates in the crew a self-pressure, most of the time unconscious, for accomplishing the flight schedule on account of the commitments undertaken by the candidate in campaign, and, therefore, the specific characteristics of this type of flight pose demands in terms of performance that may have influenced the pilots to operate with reduced safety margins.
- The meteorological conditions were close to the safety minimums for the approach and below the minimums for the circle-to-land procedure prescribed in the ECHO 1 approach. However, such conditions, by themselves, would not represent risk for the operation, if the profile of the ECHO 1 procedure was performed in accordance with the parameters established in the aeronautical publications and the flight parameters defined by the aircraft manufacturer. Upon verifying that the above mentioned parameters were not complied with, one observes that the meteorological conditions became a complicating factor for flying the aircraft, rendering it difficult to be stabilized on the final approach, and a go-around became necessary, as a result.
- In the scenario of the aircraft collision with the ground, there were aspects favorable to the occurrence of spatial disorientation, such as: reduction of the visibility on account of meteorological conditions, stress and workload increase due to the missed approach procedure, maneuvers with a G-load above 1.15G, and a possible loss of situational awareness. The large pitch-down angle, the high speed, and the power developed by the engines at the moment of impact are also evidence compatible with incapacitating disorientation, and point towards a contribution of this factor.
- The integration between the pilots may have been hindered by their little experience working together as one crew, and also by their different training background. In addition, the personal characteristics of the captain, as a more impositive and confident person, in contrast with the more passive posture of the copilot, may also have hampered the crew dynamics in the management of the flight.
- In the seven days preceding the day of the accident, the crew was in conformity with the Law 7183 of 5 April 1984 in relation to both duty time and rest periods. However, the analysis of copilot’s voice, speech, and language indicated compatibility with fatigue and somnolence, something that may have contributed to the degradation of the crew’s performance.
- Their lack of training of missed approach procedures in CE 560XLS+ aircraft may have demanded from the crew a higher cognitive effort in relation to the conditions required for the aircraft model, since they possibly did not have conditioned behaviors for controlling the flight and that could otherwise provide them with more agility with regard to the cockpit actions. Thus, they probably missed the skills, knowledge, and attitudes that would allow them to more adequately perform their activities in that operational context.
- Even though Santos Radio reported, in the first contact with the aircraft, that the aerodrome was operating IFR, the messages transmitted to the aircraft did not include the conditions of ceiling, visibility, and SIGMET information (ICA 100-37). This may have contributed to reducing the crew’s situational awareness, since the last information accessed by them was probably the 11:00 UTC SBST METAR, which reported VMC conditions for operation in the aerodrome. Thus, the pilots may have built a mental model of unreal SBST meteorological conditions more favorable to the operation.
- After coordination of the descent, the PR-AFA aircraft made a left turn and, for an unknown reason, deviated from the W6-airway profile, reporting six positions that were not compatible with the real flight path until the moment it started a final approach. This approach was different from the trajectory of the final approach defined for the ECHO 1 procedure, and was flown with speed parameters different from those recommended by the aircraft manufacturer. These aspects reduced the chances of the aircraft to align with the final approach in a stabilized manner. The fact that the aircraft made a low pass over the runway and then a left turn at low altitude in weather conditions below the minimum established in the circle-to-land procedure instead of performing the profile prescribed in the ECHO 1 approach chart also resulted in risks to the operation, and created conditions which were conducive to spatial disorientation.
- Since the captain had already conducted FMS visual approaches on other occasions, his acquired work-memory may have strengthened his confidence in performing the procedure again, even though in another scenario, on account of the human being tendency to rely on previous successful experiences.
- A poor perception on the part of the pilots relative to the real meteorological conditions on the approach may have compromised their level of situational awareness, thus leading the aircraft to a condition of operation below the safe minimums.
- The TAF/GAMET weather prognostics with validity up to 12:00 UTC, and available to the crew at the time the flight plan was filed at the AIS-RJ, indicated a possibility of degradation of the ceiling and visibility parameters on account of rain associated with mist, encompassing the duration of the aforementioned flight, especially in the area of SBST. The 11:00 UTC satellite image and the SIGMET valid from 10:30 UTC to 13:30 UTC, also showed an active cold front in the Southeast with stratiform cloud layers over SBST and a forecast of convective cells with northeasterly movement at an average speed of 12kt. Despite the availability of such information, the crew may not have made a more accurate analysis showing the swift deterioration of the weather conditions in the period between their takeoff from SBRJ and the approach to SBST, and thus may have failed to plan their conduct of the flight in accordance with the weather conditions forecast by the meteorological services.
- Despite having the C560 qualification required to operate the CE 560XLS+aircraft, the pilots were not checked by the employers as to their previous experience on this kind of equipment, or as to the need of transition training and/or specific formation to fly the PRAFA aircraft. The adoption of a formal process for the recruitment, selection, monitoring and evaluation of the performance of the professionals could have identified their training needs for that type of aircraft.
- Although the RBAC 61 requires pilots to undergo flight instruction and proficiency checks to switch between models of the CE 560XL family, the need of specific training was only clarified on 4 July 2014, with the publication of the ANAC Supplementary Instruction (IS 61-004, Revision A). Until that date, this need could only be determined by means of consultation of the FSB Report, made available only on the FAA website. In this context, the PR-AFA pilots would only be evaluated on the CE 560XLS+ aircraft on the occasion of their type revalidation, which would take place shortly before the expiration date of their C560 qualifications, which were valid until October 2014 (captain), and May 2015 (copilot). The fact that there was a qualification (C560) that was shared for the operation of C560 Citation V, C560 Encore, C560 Encore+, CE 560XL, CE 560XLS, or CE 560XLS + aircraft was not enough to make the DCERTA system refuse flight plans filed by pilots who lacked proper training to operate one of the aforementioned aircraft models. The RBAC 67 contained physical and mental health requirements which were not clear, inducing physicians to resort to other publications for guidance and support of their decisions and judgments relative to the civil aviation personnel. The absence of clear requirements to be adopted as the acceptable minimum for the exercise of the air activity, led the physicians responsible for judging the pilots’ health inspections’ to use their own discretion on the subject, opening gaps that could allow professionals not fully qualified to perform functions in flight below the minimum acceptable safety levels.
- Considering the possibility that the captain accumulated tasks as a result of a possible difficulty of the copilot in assisting him at the beginning of the missed approach procedure, such accumulation may have exceeded his ability to deal with the tasks, leading him to committing piloting errors and/or experiencing spatial disorientation.

The following findings were identified:
- The copilot was not certified in the C525 type aircraft,
- The aircraft was above the maximum landing weight limit, but within the balance limit,
- On 13JUN2014, there was a NOTAM in force, informing the prohibition of jet aircraft operation in SWNH,
- The pilot acted incorrectly on the handle of the auxiliary gear control, thinking that he was applying the emergency brake, making the braking of the aircraft impossible.
- The activation of the incorrect lever for the emergency braking of the aircraft was due to insufficient training received by the pilot for the use of the system in question, thus compromising the proper management of the abnormal condition.
- The emergency brake actuator handle of the aircraft was located outside the pilot's sight field, which, together with the lack of knowledge about the correct lever to be activated for emergency braking, favored the pilot's automatic response in triggering the lever that was most adjusted and visually available on the panel - the emergency landing gear drive lever.
- The instruction that the pilot received to operate the Cessna aircraft, model 525 did not emphasize in the theoretical phase the proper use of the emergency brake, nor contemplated training for the use of this system.
- Despite having a lot of experience in aviation, the pilot was little experienced in the aircraft and still did not know basic functionalities like the use of the emergency brake and the engine shutdown through the evacuation checklist procedure.

Collision with a tapir during takeoff, causing severe damages to the right main gear.
The following findings were identified:
- The lack of isolation of the operational area allowed the land animal to enter the runway for landings and takeoffs, contributing to the accident.
- The crew did not notice the presence of the land animal on the runway early enough to abort the takeoff without extrapolating the runway limits and avoiding collision.
- The presence of the land animal (Tapirus terrestris) interfered with the operation and led to the collision of the right main landing gear.

The following findings were identified:
- It was found that there was a restriction on the articulation movement of the right nose landing gear door and that the weight of this landing gear was not sufficient to overcome such restriction.
Upon inspecting the hinges, it was found that there were no signs of recent lubrication, allowing the hypothesis of occurrence of any deviation or non-adherence to the inspection and lubrication requirements established by the manufacturer leading to a the scenario favorable to the right door movement restriction. The issue of the maintenance could also be related to some deviation, or nonadherence to the requirements established for the service of widening the holes of the hinges concerning the coating and corrosion protection of the worked surface. As a result, the area could have been more susceptible to corrosive processes.
- The maintenance program, established by the manufacturer, may have contributed to the occurrence by not establishing adequate preventive maintenance parameters for the landing gear doors that were modified by reworking the hinges, incorporating larger radial pins and widening the lobe holes.
- It was not possible to determine the causal root of the EDP1 gasket extrusion, which caused the leakage of hydraulic oil that caused the hydraulic system 1 to fail.