Brazil

The following factors were identified:
- The pilot may have displayed a complacent attitude, both in relation to the operation of the aircraft in general and to the need to accommodate his employers’ demands for arriving in SBJF. It is also possible to infer a posture of excessive self-confidence and confidence in the aircraft, in spite of the elements which signaled the risks inherent to the situation.
- It is possible that the different levels of experience of the two pilots, as well as the copilot’s personal features (besides being timid, he showed an excessive respect for the captain), may have resulted in a failure of communication between the crewmembers.
- It is possible that the captain’s leadership style and the copilot’s personal features resulted in lack of assertive attitudes on the part of the crew, hindering the exchange of adequate information, generating a faulty perception in relation to all the important elements of the environment, even with the aircraft alerts functioning in a perfect manner.
- The meteorological conditions in SBJF were below the minima for IFR operations on account of mist, with a ceiling at 100ft.
- The crew did not inform Juiz de Fora Radio about their passage of the MDA and, even without visual contact with the runway, deliberately continued in their descent, not complying with the prescriptions of the items 10.4 and 15.4 of the ICA 100-12 (Rules of the Air and Air Traffic Services).
- The crew judged that it would be possible to continue descending after the MDA, even without having the runway in sight.

The collision with water and the subsequent accident was the consequence of the decision of the crew to continue the approach at low altitude to maintain a visual contact with the ground. At the time of the accident, the visibility was limited and weather conditions were marginal.

There was sufficient fuel in the tanks at the time of the accident as the aircraft was refueled prior to departure for a 5-hour flight. The exact cause of the double engine failure remains unknown. When the right engine failed, the pilot was flying at an altitude of 330 feet which was below the minimum safe altitude fixed at 500 feet. Also, he was apparently using his cell phone.

The following factors were identified:
- Upon intercepting the final leg for landing, the aircraft crossed the approach axis, and the pilot, in an attempt to make the aircraft join the approach axis again, may have depressed the rudder pedal in an inadequate manner, inadvertently making the aircraft enter a Cross Control Stall.
- The pilot, intentionally, violated a number of aeronautical regulations in force in order to fly an aircraft for which he had no training and was not qualified.
- The short experience of the pilot in the aircraft model hindered the correct identification of the situation and the adoption of the necessary corrective measures.
- The DCERTA’s vulnerability allowed a non-qualified pilot to file a flight notification by making use of the code of a qualified pilot. Thus, the last barrier capable of preventing the accident flight to be initiated was easily thrown down, by making it difficult to implement a more effective supervisory action.

It was determined that the loss of control results from the fact that the flight controls were locked. Investigations show that the pilot failed to prepare the flight properly, that he did not follow the pre takeoff checklist and that he rushed the departure. It was reported that the operator was using since two years a control lock that had not been approved by the Civil Aviation Authority, and that no procedure had been put in place place concerning this lock system.

The following findings were identified:
a) The pilots had valid aeronautical medical certificates;
b) The pilots had valid technical qualification certificates;
c) The aircraft captain had qualification and enough experience for the flight in question;
d) The copilot was under training;
e) The aircraft had a valid airworthiness certificate;
f) The planning of the flight from SBSP to SBBE was done by the pilot in command, who took in consideration an aircraft with a full load of fuel;
g) The flight plan read that the fuel endurance was 7 hours and 30 minutes of flight, for an estimated elapse time of 5 hours and 40 minutes at FL230;
h) When the aircraft was passing over the city of Palmas, State of Tocantins, the pilots decided, in conjunction, to proceed non-stop to the destination, discarding the need to make an intermediate landing for refueling;
i) The aircraft was registered in the passenger transport category (TPP) and was engaged in the transport of a sick person;
j) The fuel quantity indicators and the fuel flow indicators of the aircraft were not showing dependable information;
k) The flight plan for the leg betwren SBSP and SBBE contained information of sick person transportation, but there was no sick person on board;
l) The aircraft made a ditching near the banks of Guajará Bay, at a distance of approximately 1,200 meters from the threshold of runway 06 of SBBE;
m) The passengers and crew were rescued by Brazilian Navy servicemen on duty on the Naval Base of Val de Cans;
n) One of the pilots and both passengers got out uninjured, while the other pilot suffered minor injuries; and
o) The aircraft sustained substantial damage.
Contributing factors:
Concerning the operation of the aircraft
a) Attitude – a contributor
The captain failed to comply with norms and procedures by accepting to fly an aircraft on his day of rest, even knowing that he was to start his on-call duty hours as soon as he landed in SBBE.
He also showed to be overconfident when he decided to fly directly from SBSP to SBBE, trusting the 7-hour fuel endurance of his aircraft and the fuel consumption information displayed by the instruments, even after identifying their malfunction. The pilot under training, in turn, was complacent by accepting and agreeing with the pilot-in-command’s decision, without questioning his calculations or motivations for flying direct to the destination.
b) Motivation – a contributor
The captain was eager to return to SBBE on that same day, because he was supposed to start his on-call duty hours in the air taxi company for which he worked.
c) Decision-making process – a contributor
The captain failed to comply with important aspects concerning the route conditions and aircraft instruments by making a decision to fly directly from SBSP to SBBE.
Psychosocial information
a) Communication – a contributor
There was lack of assertiveness on the part of the copilot since he did not question the captain’s calculations and/or motivations to fly non-stop, when he (the copilot) considered that making a stop for refueling would be safer.
b) External influence – a contributor
The involvement of the captain with activities of another company on that same day, in addition to events belonging to his private life, had influence on his decisions in the initial planning of the flight and during the flight en route.
Organizational information
a) Work organization – a contributor
The company delegated responsibility for the entire planning of the flight to the pilots. Therefore, there was not any interference on the part of the company in the crew’s work day and in the legs defined for the flight.
b) Organizational culture – a contributor
The fact that the company performed an operation for which it was not certified reflected the fragility of an organizational culture which allowed it to perform activities unfavorable to operational safety.
Operational Factor
Concerning the operation of the aircraft
a) Flight indiscipline – a contributor
On several occasions during the flight, the pilots failed to comply with the norms and regulations in force, such as the sections 91.167 and 91.205 of the RBHA 91, the Pilot Operating Handbook and FAA Approved Airplane Flight Manual, and the Lei do Aeronauta (Law of the Aeronaut, Law nº 7.183 of 5 April 1984).
b) Training – undetermined
Before the ditching, the pilot unlocked the rear door of the aircraft and, then, failed to instruct the passengers as to the opening of the emergency exit. This fact shows a probable deviation in the process of training previously received by the captain, since the procedure prescribed for the situation was to abandon the aircraft through the emergency exit, which had to be unlocked after the ditching.
c) Piloting judgment – a contributor
At the moment of their decision to proceed non-stop to the destination, there was an inappropriate evaluation on the part of the crew, because they did not consider the hourly consumption until that point, and the malfunction of the fuel capacity indicator did not allow them to know the exact amount of fuel remaining in the tanks.
d) Flight planning – a contributor
There was a mistake on the part of the captain relative to the planning of the flight, since, in addition to a total flight time of 5 hours and 40 minutes, he did not consider the fuel necessary to fly to an alternate airport plus 45 minutes of flight. The captain and the pilot under training made an inappropriate evaluation of the effects brought by the operational conditions along the flight route.

Late use of the normal brake systems on part of the crew after landing, causing the aircraft to overran. The captain had the habit of braking the aircraft while using the reverse thrust systems only in order to save the braking systems. Doing so, the use of the normal brakes was delayed.

Human Factors
Medical Aspect
- Anxiety
The perception of danger especially by the first officer affected the communication between the pilots and may have inhibited a more assertive attitude, which could have led to an emergency landing on the beach, minimizing the consequences of the accident.
Psychological Aspect
- Attitude
Operational decisions during the emergency may have resulted from the high confidence level, that the captain had acquired in years of flying and experience in aviation, as well as the captain's resistance to accept opinions different to his own.
- Emotional state
According to CVR recordings there was a high level of anxiety and tension even before the abnormal situation. These components may have influenced the judgment of conditions affecting the operation of the aircraft.
- Decision making
The persistence to land on runway 36 during the emergency, even though the first officer recognized the conditions no longer permitted to reach the airport, reflects misjudgment of operational information present at the time.
- Signs of stress
The unexpected emergency at takeoff and the lack of preparation for dealing with it may have invoked a level of stress with the crew, that negatively affected the operational response.
Psychosocial Information
- Interpersonal relations
The historical differences between the two pilots possibly hindered the exchange of information and created a barrier to deal with the adverse situation.
- Dynamic team
The present diverging intentions of how to proceed clearly show cooperation and management issues in the cockpit. This prevented the choice of best alternative to achieve a safe emergency landing when there were no options left to reach the airport.
- Company Culture
The company was informally divided into two groups, whose interaction was impaired. It is possible that this problem of interaction continued into the cockpit management during the in flight emergency, with one pilot belonging to one and the other to the other group.
Organizational Information
- Education and Training
Deficiencies of training provided by the operator affected the performance of the crew, who had not been sufficiently prepared for the safe conduct of flight in case of emergency.
- Organizational culture
The actions taken by the company indicate informality, which resulted in incomplete operational training and attitudes that endangered the safety.
Operational Aspects
According to data from the flight recorder the rudder pedal inputs were inadequate to provide sufficient rudder deflection in order to compensate for asymmetric engine power.
The values of side slip reached as result of inadequate rudder pedal inputs penalized the performance of the aircraft preventing further climb or even maintaining altitude.
In the final phase of the flight, despite the airspeed decaying below Vmca, despite continuous stall warnings and despite calls by the first officer to not hold the nose up in order to not stall the captain continued pitch up control inputs until the aircraft reached 18 degrees nose up attitude and entered stall.
- Crew Coordination
The delay in retracting the landing gear after the first instruction by the captain, the instruction of the captain to feather the propeller when the propeller had already been feathered as well as the first officer's request the captain should initiate the turn back when the aircraft was already turning are indicative that the crew tasks and actions were not coordinated.
Emergency procedures provided in checklists were not executed and there was no consensus in the final moments of the flight, whether the best choice (least critical option) was to return to the runway or land on the beach.
- Oblivion
It is possible in response to the emergency and influenced by anxiety, that the crew may have forgotten to continue into the 3rd segment of the procedure provided for engine failure on takeoff at or above V1 while trying to return to the airfield shortly after completion of the 2nd segment while at 400ft.
- Pilot training
The lack of training of engine failures on takeoff at or above V1, similar as is recommended in the training program, led to an inadequate pilot response to the emergency. The pilots did not follow the recommended flight profile and did execute the checklist items to be carried out above 400 feet.
- Pilot decisions
The pilots assessed that the priority was to return to land in opposite direction of departure and began the turn back at 400 feet, which added to the difficulty of flying the aircraft. At 400 feet the aircraft maintained straight flight and a positive rate of climb requiring minor flight control inputs only, which would have favored the completion of the emergency check list items in accordance with recommendations by the training program.
After starting the turn the crew would needed to adjust all flight controls to maintain intended flight trajectory in addition to working the checklists, the turn thus increased workload. It is noteworthy that the remaining engine developed sufficient power to sustain flight.
- Supervision by Management
The supervision by management did not identify that the training program provided to pilots failed to address engine failure above V1 while still on the ground and airborne.
It was not identified that the software adopted by the company to dispatch aircraft used the maximum structural weight (6,600 kg) as maximum takeoff weight for departures from Recife.
On the day of the accident the aircraft was limited in takeoff weight due to ambient temperature. Due to the software error the aircraft took off with more than the maximum allowable takeoff weight degrading climb performance.
Mechanical Aspects
- Aircraft
Following the hypothesis that the fatigue process had already started when the turbine blade was still attached to the Russia made engine, the method used by the engine manufacturer for assessment to continue use of turbine blades was not able to ensure sufficient quality of the blade, that had been mounted into position 27 of the left hand engine's Gas Generator Turbine's disk.
- Aircraft Documentation
The documentation of the aircraft by the aircraft manufacturer translated into the English language did not support proper operation by having confusing texts with different content for the same items in separate documents as well as translation errors. This makes the documentation difficult to understand, which may have contributed to the failure to properly implement the engine failure checklists on takeoff after V1.
An especially concerning item is the "shutdown ABC (Auto Bank Control)", to be held at 200 feet height, the difference between handling instructed by the checklist and provided by the flight crew manual may have contributed to the non-performance by the pilots, aggravating performance of the aircraft.