Scheduled Revenue Flight

The Air Accident Investigation Sector determines that the causes of the Accident are:
(a) During the attempted go-around, except for the last three seconds prior to impact, both engine thrust levers, and therefore engine thrust, remained at idle. Consequently, the Aircraft’s energy state was insufficient to sustain flight.
(b) The flight crew did not effectively scan and monitor the primary flight instrumentation parameters during the landing and the attempted go-around.
(c) The flight crew were unaware that the autothrottle (A/T) had not responded to move the engine thrust levers to the TO/GA position after the Commander pushed the TO/GA switch at the initiation of the FCOM Go-around and Missed Approach Procedure.
(d) The flight crew did not take corrective action to increase engine thrust because they omitted the engine thrust verification steps of the FCOM Go-around and Missed Approach Procedure.
The Investigation determines that the following were contributory factors to the Accident:
(a) The flight crew were unable to land the Aircraft within the touchdown zone during the attempted tailwind landing because of an early flare initiation, and increased airspeed due to a shift in wind direction, which took place approximately 650 m beyond the runway threshold.
(b) When the Commander decided to fly a go-around, his perception was that the Aircraft was still airborne. In pushing the TO/GA switch, he expected that the autothrottle (A/T) would respond and automatically manage the engine thrust during the go-around.
(c) Based on the flight crew’s inaccurate situation awareness of the Aircraft state, and situational stress related to the increased workload involved in flying the go-around maneuver, they were unaware that the Aircraft’s main gear had touched down which caused the TO/GA switches to become inhibited. Additionally, the flight crew were unaware that the A/T mode had remained at ‘IDLE’ after the TO/GA switch was pushed.
(d) The flight crew reliance on automation and lack of training in flying go-arounds from close to the runway surface and with the TO/GA switches inhibited, significantly affected the flight crew performance in a critical flight situation which was different to that experienced by them during their simulated training flights.
(e) The flight crew did not monitor the flight mode annunciations (FMA) changes after the TO/GA switch was pushed because:
1. According to the Operator’s procedure, as per FCOM Flight Mode Annunciations (FMA), FMA changes are not required to be announced for landing when the aircraft is below 200 ft;
2. Callouts of FMA changes were not included in the Operator’s FCOM Go-Around and Missed Approach Procedures.
3. Callouts of FMA changes were not included in the Operator’s FCTM Go-Around and Missed Approach training.
(f) The Operator’s OM-A policy required the use of the A/T for engine thrust management for all phases of flight. This policy did not consider pilot actions that would be necessary during a go-around initiated while the A/T was armed and active and the TO/GA switches were inhibited.
(g) The FCOM Go-Around and Missed Approach Procedure did not contain steps for verbal verification callouts of engine thrust state.
(h) The Aircraft systems, as designed, did not alert the flight crew that the TO/GA switches were inhibited at the time when the Commander pushed the TO/GA switch with the A/T armed and active.
(i) The Aircraft systems, as designed, did not alert the flight crew to the inconsistency between the Aircraft configuration and the thrust setting necessary to perform a successful go-around.
(j) Air traffic control did not pass essential information about windshear reported by a preceding landing flight crew and that two flights performed go-arounds after passing over the runway threshold. The flight crew decision-making process, during the approach and landing, was deprived of this critical information.
(k) The modification of the go-around procedure by air traffic control four seconds after the Aircraft became airborne coincided with the landing gear selection to the ‘up’ position. This added to the flight crew workload as they attentively listened and the Copilot responded to the air traffic control instruction which required a change of missed approach altitude from 3,000 ft to 4,000 ft to be set. The flight crews’ concentration on their primary task of flying the Aircraft and monitoring was momentarily affected as both the FMA verification and the flight director status were missed.

The main cause of this accident is wrong behavior of the pilot which descripted as:
- Decision to make a landing on short field RWY 13 with tailwind.
- Un stabilized landing against on normal flight profile
- Weak, obviously, CRM in cockpit.
- Poor judgment and not accomplishing a go around while performing a unstabilized approach.
- Improper calculating of landing speed without focusing on the tailwind component
Contributing factors:
- Anti-skid failures of RH landing gear causing prolong landing distance.
- Instantaneous variable wind condition on aerodrome traffic pattern.
- Late activating of airbrakes and spoilers (especially airbrakes) with tailwind cause to increase the landing roll distance.

It was determined that the accident was the consequence of an in-flight fire in the cockpit but investigations were unable to establish the exact origin of the fire. Following the fire that probably resulted from an oxygen leak from the copilot's quick-fit mask system, both pilots left the cockpit in a hurry and were apparently unable to find and use the fire extinguisher. To this determining element, three possible contributory factors have been identified: a blanket charged with static electricity requested by the captain to sleep; fatty substances being part of the meal served to the pilots, and a high probability of a lit cigarette or a cigarette butt burning in an ashtray while the crew smoked regularly in the cockpit. The experts also noted unprofessional behavior by the flight crew who listened to music, made multiple comings and goings in the cockpit as well as a lack of attention about flight monitoring procedures.

The accident was caused by the failure of the nose landing gear (nose gear up) due to over-extension of the shock absorber which caused interference between the tires and the NLG compartment and locked the NLG in a retracted position. The over-extension was caused by the incorrect installation of some internal components of the shock absorber during the replacement of the internal seals the day before the accident.
The following factors contributed significantly to the improper activity conducted at maintenance:
- the insufficient experience of technical personnel in carrying out the maintenance tasks conducted on the NLG;
- the lack of controls on the operations carried out, deemed unnecessary by the CAMO engineering department;
- the lack of definition of roles and tasks during the planning phase of the maintenance work;
- the operational pressure on maintenance personnel, arising from the need to conclude maintenance operations quickly in order not to penalize the management of the aircraft;
- the insufficient clarity and lack of sensitive information in the maintenance tasks and related figures contained in the AMM, regarding the replacement of internal shock absorber seals, subsequently made clearer by the manufacturer;
- the reported black and white printing of the applied AMM procedures, which could have made the warnings in the manual barely legible.

The following findings were identified:
- The condition of the runway at Cuenca airport, which at the time of the plane's landing was contaminated with water and slippery.
- The landing was made after a non-stabilized approach with a tailwind.
- During seven seconds, the crew continued the approach with an excessive rate of descent of 1,186 feet, 186 feet above the limit of 1,000 feet.
- The non-application of the Maximum Performance Landing procedure recommended by the aircraft manufacturer for landing on contaminated runways.
- The dispatch of the flight with 1,500 kg of fuel more than the amount of fuel usually used for this flight.
- Omission of the runway length calculation necessary to perform the landing using the braking efficiency information.
- The crew's decision to make the final approach with three red and one white lights, using the PAPI system, induced by the information in the Terminal Information document issued by the company, which authorized this procedure.
- The use of confusing terminology in the Terminal Information document, which used terms applicable to the Airbus fleet, instead of Embraer's.
- The crew's decision not to perform the thwarted approach maneuver after the maximum allowable vertical speed was exceeded and visibility was apparently limited after the minima were exceeded.
- Incorrect use of aircraft braking aids, in this case reverse braking aids
- The application of the emergency brake that inhibits the antiskid system.
- Lack of implementation of adequate management of crew resources, particularly within the cockpit.
- Lack of training in the use of tables for track distance calculation.
- In reference to landing conditions, the aircraft needed a runway length of 2,122 metres while the available distance was 1,900 metres.

Findings as to causes and contributing factors:
1. Neither pilot had considered that the combination of landing at night, in reduced visibility, with a crosswind and blowing snow, on a runway with no centreline lighting, was a hazard that may create additional risks.
2. The blowing snow made it difficult to identify the runway centreline markings, thereby reducing visual cues available to the captain. This situation was exacerbated by the absence of centreline lighting and a possible visual illusion caused by blowing snow.
3. Due to the gusty crosswind conditions, the aircraft drifted to the right during the landing flare, which was not recognized by the crew.
4. It is likely that the captain had difficulty determining aircraft position during the landing flare.
5. The flight crew’s decision to continue with the landing was consistent with plan continuation bias.
6. During landing, the nosewheel struck the compacted snow windrow on the runway, causing the nose landing gear to collapse.

Findings as to risk:
1. If aircraft are not equipped with a 406 MHz-capable emergency locator transmitter, flight crews and passengers are at increased risk of injury or death following an accident because search-and-rescue assistance may be delayed.
2. If operators do not have defined crosswind limits, there is a risk that pilots may land in crosswinds that exceed their abilities, which could jeopardize the safety of flight.
3. If composite propeller blades contact objects and separate, and then strike or penetrate the cabin, there is a risk of injury or death to occupants seated in the propeller’s plane of rotation.
4. If modern crew resource management training is not a regulatory requirement, then it is less likely to be introduced by operators and, as a result, pilots may not be fully prepared to recognize and mitigate hazards encountered during flight.
5. If organizations do not use modern safety management practices and do not have a robust safety culture, then there is an increased risk that hazards will not be identified and mitigated.
6. When testing an emergency locator transmitter’s (ELT) automatic activation system, a sticking g-switch may go undetected if more than 1 football throw is necessary to activate the ELT. As a result, the ELT might not activate during an accident, and search-and-rescue assistance may be delayed, placing flight crews and passenger at an increased risk for injury or death.

The fatal air accident to the Boeing 737-8KN A6-FDN aircraft occurred during the second go around, due to an incorrect aircraft configuration and crew piloting, the subsequent loss of PIC’s situational awareness in nighttime in IMC. This resulted in a loss of control of the aircraft and its impact with the ground. The accident is classified as Loss of Control In-Flight (LOC-I) occurrence.
Most probably, the contributing factors to the accident were:
- The presence of turbulence and gusty wind with the parameters, classified as a moderate to-strong "windshear" that resulted in the need to perform two go-arounds;
- The lack of psychological readiness (not go-around minded) of the PIC to perform the second go-around as he had the dominant mindset on the landing performance exactly at the destination aerodrome, having formed out of the "emotional distress" after the first unsuccessful approach (despite the RWY had been in sight and the aircraft stabilized on the glide path, the PIC had been forced to initiate go-around due to the windshear warning activation), concern on the potential exceedance of the duty time to perform the return flight and the recommendation of the airline on the priority of landing at the destination aerodrome;
- The loss of the PIC’s leadership in the crew after the initiation of go-around and his "confusion" that led to the impossibility of the on-time transition of the flight mental mode from "approach with landing" into "go-around";
- The absence of the instructions of the maneuver type specification at the go-around callout in the aircraft manufacturer documentation and the airline OM;
- The crew’s uncoordinated actions during the second go-around: on the low weight aircraft the crew was performing the standard go-around procedure (with the retraction of landing gear and flaps), but with the maximum available thrust, consistent with the Windshear Escape Maneuver procedure that led to the generation of the substantial excessive nose-up moment and significant (up to 50 lb/23 kg) "pushing" forces on the control column to counteract it;
- The failure of the PIC within a long time to create the pitch, required to perform go around and maintain the required climb profile while piloting aircraft unbalanced in forces;
- The PIC’s insufficient knowledge and skills on the stabilizer manual trim operation, which led to the long-time (for 12 sec) continuous stabilizer nose-down trim with the subsequent substantial imbalance of the aircraft and its upset encounter with the generation of the negative G, which the crew had not been prepared to. The potential impact of the somatogravic "pitch-up illusion" on the PIC might have contributed to the long keeping the stabilizer trim switches pressed;
- The psychological incapacitation of the PIC that resulted in his total spatial disorientation, did not allow him to respond to the correct prompts of the F/O;
- The absence of the criteria of the psychological incapacitation in the airline OM, which prevented the F/O from the in-time recognition of the situation and undertaking more decisive actions;
- The possible operational tiredness of the crew: by the time of the accident the crew had been proceeding the flight for 6 hours, of which 2 hours under intense workload that implied the need to make non-standard decisions; in this context the fatal accident occurred at the worst possible time in terms of the circadian rhythms, when the human performance is severely degraded and is at its lower level along with the increase of the risk of errors.
The lack of the objective information on the HUD operation (there were no flight tests of the unit carried out into the entire range of the operational G, including the negative ones; the impossibility to reproduce the real HUD readings in the progress of the accident flight, that is the image the pilot was watching with the consideration of his posture in the seat trough the stream video or at the FFS) did not allow making conclusion on its possible impact on the flight outcome. At the same time the investigation team is of the opinion that the specific features of the HUD indication and display in conditions existed during final phase of the accident flight (severe turbulence, the aircraft upset encounter with the resulting negative G, the significant difference between the actual and the target flight path) that generally do not occur under conditions of the standard simulator sessions, could have affected the situational awareness of the PIC, having been in the highly stressed state.