Charter/Taxi (Non Scheduled Revenue Flight)

The following findings were identified:
- The pilot took the risks inherent to that flight when he accepted to be the only crewmember on a night-time flight with an aircraft in which he lacked enough experience. It is therefore considered that the pilot was complacent when he accepted to fly the aircraft under those circumstances, taking the risks associated with the operation.
- The fact that the pilot made a phone call to his father, to tell that he was feeling insecure for conducting the flight, may be considered an indication that he was not confident, and this condition may have influenced negatively his operational performance during the descent procedure.
- It is possible that the motivation of the pilot in making a fast progress in his career contributed to his acceptance of the challenge to operate the flight, even if he was not feeling fully confident.
- It is possible that the characteristics related to the type of flight, regions, time of the day, in addition to the fact that the pilot was flying the aircraft alone for the first time, contributed to an unclear perception of the relevant elements around him, leading him to a mistaken comprehension, which resulted in the deterioration of his ability to foresee the events.
- The operational progress of the pilot in the company was expedited and, therefore, it is possible that for this reason he did not gather the necessary experience for conducting that type of flight.
- It is possible that the way the work was organized within the company, with designation of pilots not readapted in the aircraft for night-time flights without artificial horizon, and for takeoffs with an aircraft weight above the one prescribed in the manual contributed to the event that resulted in the accident.
- It is possible that the prioritization of the financial sector, in detriment of operational safety, contributed to the designation of a single pilot with short experience for transporting nine passengers.
- It is probable that the pilot, during the preparation of the aircraft for landing, allowed the its speed and power to drop to a value below the minima required for maintenance of level flight on the downwind leg.
- It is possible that the location of the runway in an isolated area of the Amazonian jungle region, without visual references in a night-time flight, contributed to the pilot’s difficulty maintaining a sustained flight.
- It is possible that the training done by the pilot in a shortened manner deprived him from the knowledge and other technical abilities necessary for flying the aircraft.
- The decisions of the company operation sector to designate a short-experienced pilot without a copilot for a night flight destined for an aerodrome located in a jungle region without visual reference with the terrain increased the risk of the operation. Therefore, the risk management process was probably inappropriate.
- It was the first time the pilot was flying the aircraft on a night-time flight without a copilot. Since he had only little experience in the aircraft, it is possible that his operational performance was hindered in the management of tasks, weakening his situational awareness.
- It was not possible to determine whether the company chose to dispense with the copilot on account of the need to transport a ninth passenger and, thus, did not consider in a conservative manner the prescription contained in the aircraft airworthiness certificate by designating just one pilot for the flight.

Loss of control following the collision with high power cables after the crew lost visual references during an approach completed in poor weather conditions. The following contributing factors were identified:
- Inadequate meteorological information provided by the Pias Airport flight coordinator that did not reflect the actual weather condition in the area,
- Lack of a procedure card to carry out the descent, approach, landing and takeoff at Pias Airport, considering the visual and operational meteorological limitations in the area,
- The copilot training was limited and did not allow the crew to develop skills for an effective CRM in normal and emergency procedures.

It was planned that an instructor should perform the flight with the crew but he did not show up, so the captain decided to do the flight without him. On final approach to Donetsk, the visibility was limited and the captain was authorized to descent until 1,000 feet on approach where he should establish a visual contact with runway 08 or the approach lights. At this decision height, he continued the approach without any calls to the rest of the crew despite he did not establish any visual contact with the runway. During the last segment, the aircraft banked right due to a too low approach speed of 103 knots, stalled and crashed. The crew failed to monitor the approach speed, and the captain decided to continue the approach despite the visibility was below minimums. At the decision height, he should abandon the approach for a go-around procedure.

One of the engine failed after takeoff due to a fuel pump malfunction. The crew elected to return but the aircraft stalled due to an insufficient speed. Poor engine maintenance was considered as a contributing factor as well as the fact that the crew initiated the flight while the aircraft's weight was above the allowable MTOW.

Findings as to causes and contributing factors:
1. The aircraft departed Snow Lake overweight and with an accumulation of ice on the leading edges of its wings and tail from the previous flight. As a result, the aircraft had reduced take-off and climb performance and increased stall speed, and the protection afforded by its stall warning system was impaired.
2. A breakdown in the company’s operational control resulted in the flight not operating in accordance with the Canadian Aviation Regulations and the company operations manual.
3. As a result, shortly after departure, the aircraft stalled at an altitude from which recovery was not possible.
Findings as to risk:
1. If companies operate in instrument meteorological conditions for which they are not authorized, there is an increased risk that accidents may occur.
2. If Transport Canada does not provide the same degree of oversight for repetitive charter operations as it does for a scheduled operator, the risks in the operator’s activities may not be fully evaluated.
3. If passenger briefings are not provided and passengers are not properly seated and restrained, there is an increased risk of injuries to those passengers and the other occupants in the event of an accident.
4. If flights are conducted without ensuring an ice-free airframe, there is a risk of decreased aircraft performance and of loss of control and collision with terrain.
Other findings:
1. On impact, the aircraft’s seats and cabin deformed as designed, and this deformation partially attenuated the impact forces.

The following findings were identified:
- The commander was overconfident in himself and the aircraft which led him to lose the critical capacity to discern the risks involved in the procedure that was adopting. Corroborating was the fact that the pilot judged he had much knowledge in this operation and knew exactly how the aircraft responded. It can be inferred there was complacency by the copilot on the actions of the commander, during the approach at high speed, because even feeling uncomfortable, he did not make an incisive interference because he believed in the idea that the commander had done this kind of approach, with high speed, and so knowing what he was doing.
- The pilot failed to identify the location of touch down during landing and not knowing how much runway was remaining, he decided he should not rush, thus demonstrating low situational awareness and lack of awareness, impacting the proper reaction time for the situation (Rush), which was not performed , leading the occurrence in question.
- The crew failed to properly assess the information available like speed and the runway length for the realization of a safe landing, which led to a poor judgment of the situation at hand, making the decision not to adopt the missed approach procedure.
- The distance between the crew, caused unconsciously by the commander's position with excess knowledge in the operation and the aircraft, and the insecurity of the copilot in considering new and inexperienced, resulted in a lack of assertiveness of the copilot to inform, with little emphasis, the commander of his perception of excessive airspeed.
- The crew did not adopt good crew resource management, failing to communicate with assertiveness and share critical information in time prior to landing, allowing the speeding remained present until the touchdown.
- Despite having adequate experience and training, the commander did not use the resources available, such as speed brakes to reduce the aircraft approach speed.
- The variable wind direction and predominantly tail intensity equal to or greater than 10 knots, allowed excessive speed during landing.
- The crew did not adopt good crew resource management, allowing the high speed to remain present until the touchdown.
- The commander thought he would be able to perform the approach and landing with the speed above the expected.

The following findings were identified:
- Fatigue is likely to have occurred, since there are reports of high workload, capable of affecting the perception, judgment, and decision making of the crew.
- In view of the fact that the captain displayed an attitude of gratefulness toward the company which hired him, working for consecutive hours and many times more than was prescribed for his daily routine, it is possible that such high motivation may have been present in the accident flight, harming his capacity to evaluate the conditions required for a safe flight.
- The crew neither gathered nor properly evaluated the available pieces of information for the correct refueling of the aircraft, something that led to their decision of not refueling the aircraft in SBDO.
- The company crews did not usually keep fuel records, and made approximate calculations based on the fuel remaining from previous flights, whose control parameters were not dependable. Such attitudes reflected a work-group culture that became apparent in this accident.
- The pilots were presumably undergoing a condition of stress on account of the company flight routine, in which they flew every day, with little time dedicated to rest or even holidays. Under such condition, the pilots may have had their cognitive processes affected, weakening their performance in flight.
- The flights had the objective of transporting valuables, causing concern in relation to security issues involving the aircraft on the ground. Thus, it is suspected that decisions made by the pilots may have been affected by this complexity, such as, for example, deciding not to refuel the aircraft on certain locations.
- The way the work was structured in the company was giving rise to overload due to the routine of many flights and few periods of rest or holidays. This situation may have affected the crew’s performance, interfering in the analysis of the conditions necessary for a safe flight.
- The company did not monitor the performance of its pilots for the identification of contingent deviations from standard procedures, such as non-compliance with the MGO.
- Failures in the application of operational norms, as well as in the communication between the crew members, may have occurred on account of inadequate management of tasks by each individual, such as, for example, the use of the checklist and the filling out of control forms relative to fuel consumption contained in the company MGO.
- The crew judged that the amount of fuel existing in the aircraft was sufficient for the flight in question.
- The fact that the fuel gauges were not indicating the correct quantity of fuel had direct influence on the flight outcome, since the planning factors and the pilots’ situational awareness were affected.
- The crew did not analyze appropriately the amount of fuel necessary for the flight leg between SBDO and SBBI. The Mission Order did not establish the minimum amount of fuel necessary for the flight legs, and the crew had to take responsibility for the decision.
- The company was not rigorous with the filling out of aircraft logbooks and cargo manifestos, resulting that it did not have control over the operational procedures performed by the crews, and this may have contributed to the aircraft taking off with an amount of fuel that was insufficient for the flight. Although the MGO had parameters established for calculating the endurance necessary for VFR/IFR flights, the company did not define the fuel necessary in the Mission Orders, transferring the responsibility for the decision to the aircraft captain.