South America

The following findings were identified:
- The lack of a prompt identification of the aircraft stall by the captain may have deprived him of handling the controls in accordance with the prescriptions of the aircraft emergency procedures, contributing to the aircraft entry in an abnormal attitude.
- The captain’s attention was focused on the passengers sitting in the rear seats, in detriment of the flight conditions under which the aircraft was flying. This had a direct influence on the maintenance of a poor situational awareness, which may have made it difficult for the captain to immediately identify that the aircraft was stalling.
- There was complacency when the copilot functions were assumed by a person lacking due professional formation and qualification for such. Even under an adverse condition, the prescribed procedure was not performed, namely, the use of the aircraft checklist.
- The fact that the aircraft was flying under icing conditions was confirmed by a statement of the female passenger in the cockpit (CVR). The FL210 (selected and maintained by the captain) gave rise to conditions favorable to severe icing on the aircraft structure. If the prevailing weather conditions are correlated with reduction of speed (attested by the radar rerun), the connection between loss of control in flight and degraded aircraft performance is duly established.
- The rotation of the aircraft after stalling may have contributed to the loss of references of the captain’s balance organs (vestibular system), making it impossible for him to associate the side of the turn made by the aircraft with the necessary corrective actions.
- The non-adherence to the aircraft checklists on the part of the captain, in addition to the deliberate adoption of non-prescribed procedures (disarmament of the starter and “seven killers”) raised doubts on the quality of the instruction delivered by the captain.
- The captain made an inappropriate flight level selection for his flight destined for São Paulo. Even after a higher flight level was offered to him, he decided to maintain FL 210. Also, after being informed about icing on the aircraft, he did not activate the Ice Protection System, as is expressly determined by the flight manual.
- The captain had the habit of making use of a checklist not prescribed for the aircraft, and this may have influenced his actions in response to the situation he was experiencing in flight.
- His recently earned technical qualification in the aircraft type; his inattention and distraction in flight; his attitude of non-compliance with operations and procedures prescribed in manuals; all of this contributed to the captain’s poor situational awareness.
- The flight plan was submitted via telephone. Therefore, it was not possible to determine the captain’s level of awareness of the real conditions along the route, since he did not report to the AIS office in SBMG. In any event, the selection of a freezing level for the flight, considering that the front was moving along the same proposed route, was indication of inappropriate planning.
- The investigation could neither determine the whole experience of the aircraft captain, nor whether his IFR flight experience was sufficient for conducting the proposed flight, since he made decisions which went against the best practices, such as, for example, selecting a flight level with known icing.
- With a compromised situational awareness, the pilot failed to correctly interpret the information available in the aircraft, as well as the information provided by the female passenger sitting in the cockpit, and he chose to maintain the flight level under inadequate weather conditions.
- The lack of monitoring/supervision of the activities performed by the captain allowed that behaviors and attitudes contrary to flight safety could be adopted in flight, as can be observed in this occurrence.
- Apparently, there was lack of an effective managerial supervision on the part of the aircraft operator, with regard to both the actions performed by the captain and the correction of the aircraft problems.

The loss of control during taxiing was the consequence of the combination of the following factors:
- The electric pump which controls fluid pressure in the hydraulic system was not operational, generating a deficit of fluid pressure in the hydraulic system.
- The low fluid pressure warning in the hydraulic system was not recognized by the crew.
- The crew could not control the path of the aircraft due to the unavailability of nose wheel steering.
- The persistence of an informal practice among the crews of the operator on the operation of the hydraulic system, contrary to the concept of operation of the hydraulic system established by the manufacturer.
- The lack of detection of the informal practice on the operation of the hydraulic system by the operator's safety monitoring mechanisms.

Both engines failed in flight due to icing accumulation and inappropriate use of the deicing systems. The following factors were considered as contributory:
- Poor flight planning on part of the crew,
- Poor crew resources management,
- Poor crew simulator training (icing detection and dual engine failure),
- Lack of procedures relating to icing conditions and dual engine failure,
- Marginal weather conditions which contributed to ice accumulation on engines and airframe.

The following findings were identified:
- The commander was overconfident in himself and the aircraft which led him to lose the critical capacity to discern the risks involved in the procedure that was adopting. Corroborating was the fact that the pilot judged he had much knowledge in this operation and knew exactly how the aircraft responded. It can be inferred there was complacency by the copilot on the actions of the commander, during the approach at high speed, because even feeling uncomfortable, he did not make an incisive interference because he believed in the idea that the commander had done this kind of approach, with high speed, and so knowing what he was doing.
- The pilot failed to identify the location of touch down during landing and not knowing how much runway was remaining, he decided he should not rush, thus demonstrating low situational awareness and lack of awareness, impacting the proper reaction time for the situation (Rush), which was not performed , leading the occurrence in question.
- The crew failed to properly assess the information available like speed and the runway length for the realization of a safe landing, which led to a poor judgment of the situation at hand, making the decision not to adopt the missed approach procedure.
- The distance between the crew, caused unconsciously by the commander's position with excess knowledge in the operation and the aircraft, and the insecurity of the copilot in considering new and inexperienced, resulted in a lack of assertiveness of the copilot to inform, with little emphasis, the commander of his perception of excessive airspeed.
- The crew did not adopt good crew resource management, failing to communicate with assertiveness and share critical information in time prior to landing, allowing the speeding remained present until the touchdown.
- Despite having adequate experience and training, the commander did not use the resources available, such as speed brakes to reduce the aircraft approach speed.
- The variable wind direction and predominantly tail intensity equal to or greater than 10 knots, allowed excessive speed during landing.
- The crew did not adopt good crew resource management, allowing the high speed to remain present until the touchdown.
- The commander thought he would be able to perform the approach and landing with the speed above the expected.

The following findings were identified:
- Fatigue is likely to have occurred, since there are reports of high workload, capable of affecting the perception, judgment, and decision making of the crew.
- In view of the fact that the captain displayed an attitude of gratefulness toward the company which hired him, working for consecutive hours and many times more than was prescribed for his daily routine, it is possible that such high motivation may have been present in the accident flight, harming his capacity to evaluate the conditions required for a safe flight.
- The crew neither gathered nor properly evaluated the available pieces of information for the correct refueling of the aircraft, something that led to their decision of not refueling the aircraft in SBDO.
- The company crews did not usually keep fuel records, and made approximate calculations based on the fuel remaining from previous flights, whose control parameters were not dependable. Such attitudes reflected a work-group culture that became apparent in this accident.
- The pilots were presumably undergoing a condition of stress on account of the company flight routine, in which they flew every day, with little time dedicated to rest or even holidays. Under such condition, the pilots may have had their cognitive processes affected, weakening their performance in flight.
- The flights had the objective of transporting valuables, causing concern in relation to security issues involving the aircraft on the ground. Thus, it is suspected that decisions made by the pilots may have been affected by this complexity, such as, for example, deciding not to refuel the aircraft on certain locations.
- The way the work was structured in the company was giving rise to overload due to the routine of many flights and few periods of rest or holidays. This situation may have affected the crew’s performance, interfering in the analysis of the conditions necessary for a safe flight.
- The company did not monitor the performance of its pilots for the identification of contingent deviations from standard procedures, such as non-compliance with the MGO.
- Failures in the application of operational norms, as well as in the communication between the crew members, may have occurred on account of inadequate management of tasks by each individual, such as, for example, the use of the checklist and the filling out of control forms relative to fuel consumption contained in the company MGO.
- The crew judged that the amount of fuel existing in the aircraft was sufficient for the flight in question.
- The fact that the fuel gauges were not indicating the correct quantity of fuel had direct influence on the flight outcome, since the planning factors and the pilots’ situational awareness were affected.
- The crew did not analyze appropriately the amount of fuel necessary for the flight leg between SBDO and SBBI. The Mission Order did not establish the minimum amount of fuel necessary for the flight legs, and the crew had to take responsibility for the decision.
- The company was not rigorous with the filling out of aircraft logbooks and cargo manifestos, resulting that it did not have control over the operational procedures performed by the crews, and this may have contributed to the aircraft taking off with an amount of fuel that was insufficient for the flight. Although the MGO had parameters established for calculating the endurance necessary for VFR/IFR flights, the company did not define the fuel necessary in the Mission Orders, transferring the responsibility for the decision to the aircraft captain.

It was determined that the “the landing gear failed due to overload in the cylinder structure”. The fracture started in the rear section of the cylinder in a connection hole which served as a tension concentration point, and ended in the front part of the cylinder with its breakage into two parts. Following a failure of the right main gear upon landing in Montevideo on 20 October 2009, the right main landing gear was replaced by VARIG Engineering & Maintenance (VEM), but the organization responsible for the research of damage, the specification of the services necessary for the restoration of airworthiness, and the provision of the services that enabled the restoration of the aircraft to an airworthy condition was not identified. The same aircraft parts were subjected to metallurgical analysis at the Boeing Long Beach Materials, Processing and Physics [MP&P] Laboratories, in Huntington Beach, California, USA; and the technical report issued by Boeing highlighted that in one of the points of origin of the failure, the analysis had identified characteristics similar to a pre-crack point, which would have begun earlier, probably due to overload. In the tasks that led to the restoration of the aircraft airworthiness after the accident in Uruguay in 2009 (Hard-Landing), and also in subsequent periodic inspections, the existence of pre-crack traces resulting from a previous overload condition may not have been identified, something that could have resulted in a point of stress concentration.

The following factors were identified:
- The pilot may have displayed a complacent attitude, both in relation to the operation of the aircraft in general and to the need to accommodate his employers’ demands for arriving in SBJF. It is also possible to infer a posture of excessive self-confidence and confidence in the aircraft, in spite of the elements which signaled the risks inherent to the situation.
- It is possible that the different levels of experience of the two pilots, as well as the copilot’s personal features (besides being timid, he showed an excessive respect for the captain), may have resulted in a failure of communication between the crewmembers.
- It is possible that the captain’s leadership style and the copilot’s personal features resulted in lack of assertive attitudes on the part of the crew, hindering the exchange of adequate information, generating a faulty perception in relation to all the important elements of the environment, even with the aircraft alerts functioning in a perfect manner.
- The meteorological conditions in SBJF were below the minima for IFR operations on account of mist, with a ceiling at 100ft.
- The crew did not inform Juiz de Fora Radio about their passage of the MDA and, even without visual contact with the runway, deliberately continued in their descent, not complying with the prescriptions of the items 10.4 and 15.4 of the ICA 100-12 (Rules of the Air and Air Traffic Services).
- The crew judged that it would be possible to continue descending after the MDA, even without having the runway in sight.