Landing (descent or approach)

The pilot's failure to maintain control of the airplane during a night visual landing approach. Contributing to the accident was the pilot's impairment due to his use of a combination of medications.

An engine power loss for reasons that could not be determined because the airplane was not recovered.

There were no investigations about this event. Nevertheless, it was reported that the pilot was distracted and forgot to lower the landing gear on final approach.

The aircraft landed at Virgin Gorda in conditions (of weight, altitude, temperature and surface condition) where the landing distance required was very close to the landing distance available and without the required safety margin. Hence, when the performance of the brakes was not as expected, probably due to debris in the braking system, the aircraft could not be stopped on the runway. Analysis of the maintenance state of the aircraft involved in this accident indicated that the maintenance capability, processes and planning of its operator were not consistent with the standards expected in conducting international passenger charter services. This appeared also to be the case for the operational procedures and data management.

The pilot's failure to ensure that the landing gear were down and locked before touchdown. Contributing to the accident was the pilot's self-reported fatigue at the time of the accident.

Contributing factors:
- Adverse meteorological conditions - a contributor
At the moment of the impact of the aircraft, there was rain with rainfall potential of 25mm/h, covering the Paraty Bay region, and the horizontal visibility was 1,500m. Such horizontal visibility was below the minimum required for VFR landing and take-off operations. Since the SDTK aerodrome allowed only operations under VFR flight rules, the weather conditions proved to be impeding the operation within the required minimum safety limits.
- Decision-making process - a contributor
The weather conditions present in SDTK resulted in visibility restrictions that were impeding flight under VFR rules. In this context, the accomplishment of two attempts to approach and land procedures denoted an inadequate evaluation of the minimum conditions required for the operation at the Aerodrome.
- Disorientation - undetermined
The conditions of low visibility, of low height curve on the water, added to the pilot stress and also to the conditions of the wreckage, which did not show any fault that could have compromised the performance and/or controllability of the aircraft, indicate that the pilot most likely had a spatial disorientation that caused the loss of control of the aircraft.
- Emotional state - undetermined
Through the analysis of voice, speech and language parameters, variations in the emotional state of the pilot were identified that showed evidence of stress in the final moments of the flight. The pilot's high level of anxiety may have influenced his decision to make another attempt of landing even under adverse weather conditions and may have contributed to his disorientation.
- Tasks characteristics - undetermined
The operations in Paraty, RJ, demanded that pilots adapt to the routine of the operators, which was characteristic of the executive aviation. In addition, among operators, possibly because of the lack of minimum operational requirements in SDTK, the pilots who landed even in adverse weather conditions were recognized and valued by the others. Although there were no indications of external pressure on the part of the operator, these characteristics present in the operation in Paraty, RJ, may have favored the pilot's self-imposed pressure, leading him to operate with reduced safety margins.
- Visual illusions - undetermined
The flight conditions faced by the pilot favored the occurrence of the vestibular illusion due to the excess of "G" and the visual illusion of homogeneous terrain. Such illusions probably had, consequently, the pilot's sense that the bank angle was decreasing and that he was at a height above the real. These sensations may have led the pilot to erroneously correct the conditions he was experiencing. Thus, the great bank angle and the downward movement, observed at the moment of the impact of the aircraft, are probably a consequence of the phenomena of illusions.
- Work-group culture - a contributor
Among the members of the pilot group that performed routine flights to the region of Paraty, RJ, there was a culture of recognition and appreciation of those operating under adverse conditions, to the detriment of the requirements established for the VFR operation. These shared values promoted the adherence to informal practices and interfered in the perception and the adequate analysis of the risks present in the operation in SDTK.