Landing (descent or approach)

Birdstrike.

The accident was the consequence of a wrong approach configuration on part of the crew who allowed the aircraft to deviate from the approach glide above the permissible limit. The following contributing factors were reported:
- Unsatisfactory crew interactions during the approach procedure,
- Once the decision altitude was reached, the captain unreasonably left the controls to the copilot,
- The crew decided to continue the descent beyond the minimum decision height without visual contact with the runway/approach lights,
- The decision to initiate a go-around procedure was taken too late,
- The performance level of the crew may have been reduced due to a long shift,
- Poor weather conditions at destination airport.

The following findings were reported:
a. Human Factor
(1) Physiological Aspect
- There was no evidence of this aspect contributing to the occurrence of the accident.
(2) Psychological Aspect - Contributed
- The psychological aspect contributed through the generation of a high level of anxiety to perform the landing and in the diversion of the focus of attention during the approach manoeuvres to land.
- The psychological aspect was influenced by the activation of the smoke alarm which generated an increase in the workload on board.
b. Material Factor
- There were no indications that this factor contributed to the accident.
c. Operational Factor
(1) Deficient Instruction
- Although the instruction was carried out in accordance with what the standards recommend, the failures that contributed to the accident are characteristic of lack of experience in facing abnormalities simultaneously with the maintenance of flight control. Such failures could be avoided with more adequate simulator instructions and training involving the cockpit management aspects.
(2) Poor Maintenance - Undetermined .
- It was not possible to determine the cause of the activation of the 'Aft Cargo Smoke' alarm and whether the maintenance services contributed to this occurrence.
(3) Deficient Cockpit Coordination
- Inadequate performance of the duties assigned to each crew member. The procedures foreseen for the execution of descent by instrument have been modified and some have been deleted depending on the appearance of a complicator element (smoke alarm).
(4) Influence of the environment
- The dark night contributed to the creation of the 'black hole' phenomenon, or 'background figure', making it difficult to perceive external references for a possible identification of the vertical distance of the aircraft from the ground.
(5) Deficient Oversight
- The supervision, at cockpit level, contributed to the accident by the inadequate management of the resources available for the flight in the cockpit.
- Company level supervision contributed to the accident by not identifying the need for cockpit management training and providing it to the crew involved.
- Supervision, at company level, was also inadequate when climbing to the same mission, two pilots unfamiliar with the airplane to be used and in night operation.
(6) Other Operational Aspects
- The failure to comply with several 'Callouts', the non-use of the radio altimeter and the inadequate use of the 'altitude alert', as an aid to the accomplishment of the descent procedure, contributed to the occurrence of the accident.

The pilot's improper execution of an emergency procedure, after an engine failure, which resulted in a loss of airspeed and subsequent stall at an altitude too low for recovery. A factor related to the accident was the fatigue failure of a compressor turbine blade and the subsequent engine failure.

The crew mistakenly landed on the wrong runway (too short for such aircraft) and failed to initiate a go-around. It was reported that interferences occurred on frequency during the approach, causing the pilots to misinterpret ATC instructions.

The failure of senior management of GP Express to provide adequate training and operational support for the startup of the southern operation, which resulted in the assignment of an inadequately prepared captain with a relatively inexperienced first officer in revenue passenger service, and the failure of the flightcrew to use approved instrument flight procedures, which resulted in a loss of situational awareness and terrain clearance. Contributing to the causes of the accident was GP Express' failure to provide approach charts to each pilot and to establish stabilized approach criteria. Also contributing were the inadequate crew coordination and a role reversal on the part of the captain and first officer.

The failure of the beta blocking device for undetermined reason(s), and the second-pilot's inadvertent activation of the power lever, or levers, aft of the flight idle position and into the beta range, resulting in a loss of airplane control.