South America

Inadequate fuel management and incomplete execution of procedures by the Pilot, by not activating in time the fuel supply from the external tanks (OUTBD) to the internal tanks (INBD) for the feeding of both the engines, causing the fuel in the internal tanks to run out and causing both engines to stop due to fuel starvation.
Contributing Factors:
- Poor flight planning on part of the pilot by not considering the amount of minimum fuel needed and not complying with the minimum fuel amount required for domestic flights.
- Loss of situational awareness by the pilot by not following the standard operation procedures.

Contributing factors:
- Flight indiscipline – a contributor
The pilot failed to comply with the minimum fuel requirements laid down in the regulations, providing conditions for both engines to stop operating in flight, due to lack of fuel.
- Piloting judgment – a contributor
It was found in this flight an inadequate evaluation for certain parameters related to aircraft operation, particularly with regard to the influence of the chosen flight level on fuel consumption. This misjudgment led to the decision to proceed with the flight to the Aerodrome where it was intended to land, to the detriment of the more conservative option of finding a suitable place for an intermediate landing and a refueling, which led to the depletion of usable fuel in flight.
- Flight planning – a contributor
Inadequate flight preparation work, especially with regard to fuel calculation and cruise level selection, has degraded the safety level and also contributed to the actual accident.
- Decision-making process – undetermined
Difficulties in perceiving, analyzing, choosing alternatives, and acting appropriately due to inadequate judgment, may have resulted in poor assessment of flight parameters (available fuel, distance to destination, verified consumption, etc.), which may have favored the occurrence of lack of fuel failure.

Failure of the mechanical components of the shimmy damper system in each of the main landing gears which, being out of tolerance range, did not allow the correct damping of the vibrations and lateral oscillations of the wheels after touchdown, generating sequential shimmy events in both gears and causing their collapse.
Contributing factors:
- Incorrect and probable absence of measurements on mechanical components of the 'cimmetic chain for shimmy damper operation', as indicated by the operator's PM AMM Task, which would have allowed for the timely detection and replacement of out-of-tolerance components, ensuring their integrity and correct operation.
- The Service Letter 737-SL-32-057-E 'broken torsion link', does not provide for mandatory actions, it only recommends maintenance practices to prevent fractures in mechanical components of the 'cimmetic chain for shimmy damper operation'.
- Service Letter 737-SL-32-057-E 'fractures in lower torsion link', makes a proper interpretation difficult; that could induce errors to choose the corresponding AMM Task and determine its scope.

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.

The following findings were identified:
- Inadequate flight planning by the operator of the aircraft, and by the crew, by failure to properly perform dispatch procedures, takeoff performance calculations and verification of limitations imposed by operational conditions of the aerodrome according to the configuration of the aircraft.
- Wrong crew decision making by not considering a key aspect affecting aircraft performance, such as the prevailing tailwind at takeoff.
- Erroneous selection of takeoff speeds V1/VR and V2, by the crew, corresponding to an aircraft without modification in its flap system, which led to rotate the aircraft with five more knots of speed, increasing the takeoff run.
- Erroneous rotation technique applied by the Pilot, delayed maneuver that extended the long takeoff run even more.
- Loss of components (landing gear, trailing inboard flap right) and damage to functional systems (loss of engine power n°3 and hydraulic system) necessary to control the aircraft in flight.
- Loss of control in flight generated by asymmetries of lift, power and emptying of the main hydraulic systems that exceeded the capacity of the crew and made it impossible to maintain adequate directional control and stability of the aircraft.
Contributing Factors:
- Non-compliance with the Aeronautical Regulations by the operating company of the aircraft, operating to an aerodrome unsuitable for the operation of B727-200 equipment, which, in addition, was not authorized for that type of aircraft in the company's Operating Specifications, approved by the Aeronautical Authority.
- Lack of standardization and supervision of the operating company of the aircraft, allowing the operation of the B727-200 equipment, to which a modification had been applied to the flap system, with the reference tables of speeds corresponding to the aircraft without modification.
- Execution of take-off with a weight that exceeded the maximum value established in the aircraft performance charts for the conditions prevailing at the Germán Olano airport.
- Omission of the crew by not activating the Standby hydraulic system, which might have allowed emergency hydraulic pressure, to regain control of the aircraft.
- Lack of supervision by the Aeronautical Authority, which allowed for several years the operation of equipment B727-200 of the company operating the aircraft at the Germán Olano aerodrome in Puerto Carreño, when the characteristics of the aerodrome did not allow it and without the operator being authorized to operate equipment B727-200 in that aerodrome.

It was determined that the accident was the consequence of an inappropriate planning and execution of the flight, since the amount of fuel required to fly from the airport of destination to an alternate airport was not considered, nor was the amount of reserve fuel, nor the contingency fuel, nor the minimum landing fuel, quantities of fuel required by aeronautical regulations for the execution of the type of international flight that the aircraft CP-2339 was performing. The following factors were considered as contributing:
- Loss of situational awareness,
– Premature configuration of the aircraft for landing,
– Latent deficiencies,
– Lack of operational supervision and control of part of Operator,
– Organizational and operational deviation on the part of the Operator (non compliant to standard procedures).