Positioning

The pilots’ failure to use available sources of wind information before landing and recognize cues indicating the presence of the tailwind and conduct a go-around, which resulted in their landing with a significant tailwind and a subsequent runway overrun.

The pilots' failure to follow proper procedures in response to a crew alerting system warning for high engine torque values, which necessitated an off-runway emergency landing during which the airplane sustained substantial damage due to postimpact fire. Contributing to the accident was the erroneous engine torque indication for reasons that could not be determined.

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.

No investigations completed by the NTSB.

Runway excursion due to loss of directional control of the aircraft during the landing run on an unstabilized approach.
The following contributing factors were identified:
a) Unstabilized approach,
b) Adverse atmospheric conditions in the "W" area of the airport,
c) Change of designation of runway in use for landing,
d) Lack of adherence to standard operating procedures "SOPS",
e) Lack of adherence to the concepts of "CRM" resource management in the cockpit,
f) Decreased situational awareness on the part of the commander of the aircraft,
g) Flying the approach and descent visually, following an IFR descent within IMC conditions (Instrument Meteorological Conditions),
h) Wet track,
i) Lack of crew coordination,
j) Poor judgement and incorrect decision,
k) Existence of a concrete marker with a level of 10cms protruding above the road surface in the runway safety zone.

The most likely cause of the uncommanded acceleration and subsequent overspeed condition was a contamination of retained particles present within the fuel control unit (FCU). The contamination was a short-lived random condition, as evidenced by the fact that after about 30 seconds the power lever regained control of the left engine. On a general aviation flight, during the take-off run, the LJ35 LV-ZSZ suffered a runway excursion on the right side, and a subsequent aircraft fire.
The accident was due to the combination of the following factors:
- The uncommanded acceleration of the left engine at the start of the take-off run,
- The initial lack of response of the left engine to the requests of the corresponding power lever,
- The difficulties of the crew in managing an unusual condition of the aircraft in accordance with guidelines established in the AFM,
- The ambivalence in the existing regulations for the authorization of a co-pilot in an aircraft that require two pilots for certification,
- The duality in the application of safety standards allowed by the existing normative regulations.
Although unrelated, the state of the runway 05/23 protection zone at the San Fernando Aerodrome contributed to the severity of the accident.

Examination of the powerplants showed that they were probably producing medium to high power at impact. There was contradictory evidence as to whether or not the left inboard flap was fully extended at impact but it was concluded that the aircraft would have been controllable even if there had been a flap asymmetry. The possibility of a preaccident control restriction could not be discounted, although the late change of aircraft attitude showed that, had there been a restriction, it cleared itself. The evidence available suggested a loss of aircraft control while in IMC followed by an unsuccessful attempt to recover the aircraft to safe flight. It is possible that the pilot lost control through a lack of skill but this seemed highly unlikely given that he was properly licensed and had just completed an extensive period of supervised training. Incapacitation of the pilot, followed by an attempted recovery by the additional crew member, was a possibility consistent with the evidence and supported by the post-mortem report. Without direct evidence from within the cockpit, it could not be stated unequivocally that the pilot became incapacitated. Likewise, loss of control due to a lack of skill, control restriction or distraction due to flap asymmetry could not be excluded entirely. On the balance of probabilities, however, it was likely that the pilot lost control of the aircraft due to medical incapacitation and the additional crew member was unable to recover the aircraft in the height available.

Contributing factors:
- There was probably residual braking pressure in the wheel brakes during the take-off run.
- The aircraft’s parking brake was probably applied while at the holding point and not disengaged before taxing onto the runway for take-off.
- The Citation aircraft did not have an annunciator light to show that the parking brake is engaged, and the manufacturer’s before take-off checklist did not include a check to ensure the parking brake is disengaged.
- The aircraft experienced a retarded acceleration during the take-off run, and did not rotate as normal when the appropriate rotate speed was reached, resulting in a critical rejected take-off
and a runway overrun.

The crash of An-2 RA-35141 aircraft occurred during the emergency landing on a forest firebreak. The landing was urged due to in-flight engine power loss as a result of the destruction of the 62.06.02 bronze hub pouring of the master rod big end of the crank mechanism. Most probably the destruction of the bronze hub pouring was caused by a manufacturing flaw consisting in a lack of bronze friction with the steel base on a part of its surface.