Scheduled Revenue Flight

The most probable cause for the occurrence of the accident was the malfunction of the centralized crew warning system (CCAS/CAC) with erroneous activation of the flight loss of lift warning system.
The following contributing factors were identified:
- Poor crew resources management,
- Loss of situational awareness,
- Inadequate coordination during the decision-making process to deal with abnormal situations in flight,
- Ignorance of the loss of lift warning system.
- Inadequate handling of flight controls.

The following factors were identified:
- During the approach, the flight crew's attention was focused on the characteristics of the geographical relief and presence of birds, reducing their awareness as to the maintenance of the approach slope.
- The group culture of maintaining a low angle of approach led the crew to choose the runway aspect instead of the VASIS as a reference for the approach, making them susceptible to various types of spatial illusion.
- Taking into account copilot's report that he was not succeeding in correcting the aircraft glide path relative to the runway, one may suppose that he was not applying the appropriate amplitude for such correction.
- The physical characteristics of the runway 15 (the active one) contributed to a wrong perception of the ideal glide path. The pronounced acclivity of the runway, its width (narrower than the runways on which the crew was accustomed to operate), and the low terrain near the threshold, caused in the pilots a perception that they were above the ideal approach slope, leading them to seek correction, which resulted in an angle of approach below the ideal one.
- For the flight in question, the company chose two pilots who had never operated in SBQV. A crewmember with previous experience in the locality would have a higher level of awareness in relation to the specific characteristics of the aerodrome.
- No company publications were found that could provide the pilots with guidance on the specifics of SBQV, capable of helping with the management of the risks associated with the operation in that aerodrome.

Loss of control on final approach due to the movement of several passengers in the cabin, panicked by the presence of a crocodile.

- In violation of the airline's flight operation manual the captain attempted the approach to Yichun below required visibility. The airport reported 2800 meters of visibility while the manual required 3600 meters of visibility to begin the approach
- In violation of regulations by the Civil Aviation Authority the crew descended below minimum descent altitude although the aircraft was operating in fog and visual contact with the runway had not been established
- Despite the aural height announcements and despite not seeing the runway the crew continued the landing in the blind without initiating a go-around resulting in impact with terrain
Contributing factors were:
- The airline's safety management is insufficient:
* part of the flight crew arbitrarily implement the company's operations manual as the company does not follow up outstanding problems. Records suggest frequent deviations from approach profiles, i.e. deviation above or below glide slopes, excessive rates of descents and unstable approaches
* crew rostering and crew cooperation: Each of the crew was flying into Yichun for the first time despite the known safety risks at the airport, the communication and cooperation within the crew was insufficient, the crew members did not monitor each other in order to reduce human errors
* the airline's emergency training did not meet requirements, in particular the cabin crew training did not provide for hands on training on E190 cabin doors and overwing exits. Alternate means by the airline did prove ineffective and did not provide the quality China's Civil Aviation Authority requires thus leaving cabin crew unprepared to meet required cabin crew emergency response capabilities
- Parent company's Shenzhen Airlines oversight insufficient
* Shenzhen Airlines, after having taken over Henan Airlines in 2006, did not provide sufficient funding and technical support affecting the stability and safety of staff and quality management
* Air China, holding stock into Shenzhen Airlines, installed a safety supervisor but failed to address the safety management issues with Shenzhen and Henan Airlines
- No supervision by China's Civil Aviation Authority
* the license to operate the flight from Harbin to Yichun was granted without route validation and without safety management in violation of regulations
* to solve the lack of cabin crew flight attendants were certified although not meeting the relevant requirements for air transport operations
* the regional office of the Civil Aviation Authority did not communicate to their superiors that they had approved the domestic operation of the route from Harbin to Yichun permitting non-standard procedures
- China's Civil Aviation Authority safety management loopholes.

Loss of control on approach following the failure of a generator for undetermined reasons.

Execution of the flight below the angle of approach, due to a misjudgment of the crew, believing to be much higher, leading the aircraft to fly a typical trajectory of a 'black hole' illusion, which was experienced during the night-time approach to a runway with low contrast surrounded in bright focused lights, aggravated by bad weather of heavy rain.

Controlled flight into terrain after the crew descended in IMC conditions below the glide without visual contact with the ground. The following contributing factors were identified:
- The failure of the crew to initiate a go-around procedure,
- Incorrect weather forecast with regards to cloud ceiling, visibility and severe weather (fog),
- Inaccurate information about the actual weather on the glide path at the Middle Marker with course 117°, radioed to the crew 40 minutes before the accident.

Primary Cause Factor:
- Failure of the flight crew to discontinue the approach when deteriorating weather and their associated hazards to flight operations had moved into the airport (Human Factor)
Contributory Factor:
- The adverse weather condition affected the judgment and decision-making of the PIC even prior to the approach to land. With poor weather conditions being encountered, the PIC still continued the approach and landing. (Environmental Factor)
Underlying Factor:
- As a result of the bounced landing, several cockpit instruments were affected including both transponders on board. One of the nosewheels was detached and all the landing gears could not be retracted. Further, the integrity of the structure may have been affected and chance airframe failure was imminent. With all of these conditions, the Captain still opted to request for a priority landing when emergency landing was needed.

- Weather conditions indicated rain, poor visibility and low clouds in and around the airport. The information regarding prevalent weather and the required type of approach on arrival was in the knowledge of aircrew.
- Though aircrew Captain was fit to undertake the flight on the mishap day, yet his portrayed behavior and efficiency was observed to have deteriorated with the inclement weather at BBIAP Islamabad.
- The chain of events leading to the accident in fact started with the commencement of flight, where Captain was heard to be confusing BBIAP Islamabad with JIAP Karachi while planning FMS, and Khanpur Lake (Wah) with Kahuta area during holding pattern. This state continued when Captain of the mishap flight violated the prescribed Circling Approach procedure for RWY-12; by descending below MDA (i.e 2,300 ft instead of maintaining 2,510 ft), losing visual contact with the airfield and instead resorting to fly the non-standard self created PBD based approach, thus transgressing out of protected airspace of maximum of 4.3 NM into Margallas and finally collided with the hills.
- Aircrew Captain not only clearly violated the prescribed procedures for circling approach but also did not at all adhere to FCOM procedures of displaying reaction / response to timely and continuous terrain and pull up warnings (21 times in 70 seconds) – despite these very loud, continuous and executive commands, the Captain failed to register the urgency of the situation and did not respond in kind (break off / pull off).
- F/O simply remained a passive bystander in the cockpit and did not participate as an effective team member failing to supplement / compliment or to correct the errors of his captain assertively in line with the teachings of CRM due to Captain’s behavior in the flight.
- At the crucial juncture both the ATC and the Radar controllers were preoccupied with bad weather and the traffic; the air traffic controller having lost visual contact with the aircraft got worried and sought Radar help on the land line (the ATC does not have a Radar scope); the radar controller having cleared aircraft to change frequency to ATC, got busy with the following traffic. Having been alerted by the ATC, the Radar controller shifted focus to the mishap aircraft – seeing the aircraft very close to NFZ he asked the ATCO (on land line) to ask the aircraft to immediately turn left, which was transmitted. Sensing the gravity of the situation and on seeing the aircraft still heading towards the hills, the Radar controller asked the ATCO on land line “Confirm he has visual contact with the ground. If not, then ask him to immediately climb, and make him execute missed approach”. The ATCO in quick succession asked the Captain if he had contact with the
airfield – on receiving no reply from aircrew the ATCO on Radars prompting asked if he had contact with the ground. Aircrew announced visual contact with the ground which put ATS at ease.
Ensuing discussion and mutual situational update (on land line) continued and, in fact, the ATC call “message from Radar immediately turn left” was though transmitted, but by the time the call got transmitted, the aircraft had crashed at the same time.
- The accident was primarily caused by the aircrew who violated all established procedures for a visual approach for RWY-12 and ignored several calls by ATS Controllers and EGPWS system warnings (21) related to approaching rising terrain and PULL UP.