South America

It was determined that the loss of control results from the fact that the flight controls were locked. Investigations show that the pilot failed to prepare the flight properly, that he did not follow the pre takeoff checklist and that he rushed the departure. It was reported that the operator was using since two years a control lock that had not been approved by the Civil Aviation Authority, and that no procedure had been put in place place concerning this lock system.

The failure of the seal of the balance tube on the left engine intake manifold, causing a loss of manifold pressure and then a loss of engine power.
Contributing Factor:
- Discrepancies found with the quality control of the maintenance services performed on the aircraft,
- The non-assertive decisions taken during the flight when the emergency occurred.

The following findings were identified:
a) The pilots had valid aeronautical medical certificates;
b) The pilots had valid technical qualification certificates;
c) The aircraft captain had qualification and enough experience for the flight in question;
d) The copilot was under training;
e) The aircraft had a valid airworthiness certificate;
f) The planning of the flight from SBSP to SBBE was done by the pilot in command, who took in consideration an aircraft with a full load of fuel;
g) The flight plan read that the fuel endurance was 7 hours and 30 minutes of flight, for an estimated elapse time of 5 hours and 40 minutes at FL230;
h) When the aircraft was passing over the city of Palmas, State of Tocantins, the pilots decided, in conjunction, to proceed non-stop to the destination, discarding the need to make an intermediate landing for refueling;
i) The aircraft was registered in the passenger transport category (TPP) and was engaged in the transport of a sick person;
j) The fuel quantity indicators and the fuel flow indicators of the aircraft were not showing dependable information;
k) The flight plan for the leg betwren SBSP and SBBE contained information of sick person transportation, but there was no sick person on board;
l) The aircraft made a ditching near the banks of Guajará Bay, at a distance of approximately 1,200 meters from the threshold of runway 06 of SBBE;
m) The passengers and crew were rescued by Brazilian Navy servicemen on duty on the Naval Base of Val de Cans;
n) One of the pilots and both passengers got out uninjured, while the other pilot suffered minor injuries; and
o) The aircraft sustained substantial damage.
Contributing factors:
Concerning the operation of the aircraft
a) Attitude – a contributor
The captain failed to comply with norms and procedures by accepting to fly an aircraft on his day of rest, even knowing that he was to start his on-call duty hours as soon as he landed in SBBE.
He also showed to be overconfident when he decided to fly directly from SBSP to SBBE, trusting the 7-hour fuel endurance of his aircraft and the fuel consumption information displayed by the instruments, even after identifying their malfunction. The pilot under training, in turn, was complacent by accepting and agreeing with the pilot-in-command’s decision, without questioning his calculations or motivations for flying direct to the destination.
b) Motivation – a contributor
The captain was eager to return to SBBE on that same day, because he was supposed to start his on-call duty hours in the air taxi company for which he worked.
c) Decision-making process – a contributor
The captain failed to comply with important aspects concerning the route conditions and aircraft instruments by making a decision to fly directly from SBSP to SBBE.
Psychosocial information
a) Communication – a contributor
There was lack of assertiveness on the part of the copilot since he did not question the captain’s calculations and/or motivations to fly non-stop, when he (the copilot) considered that making a stop for refueling would be safer.
b) External influence – a contributor
The involvement of the captain with activities of another company on that same day, in addition to events belonging to his private life, had influence on his decisions in the initial planning of the flight and during the flight en route.
Organizational information
a) Work organization – a contributor
The company delegated responsibility for the entire planning of the flight to the pilots. Therefore, there was not any interference on the part of the company in the crew’s work day and in the legs defined for the flight.
b) Organizational culture – a contributor
The fact that the company performed an operation for which it was not certified reflected the fragility of an organizational culture which allowed it to perform activities unfavorable to operational safety.
Operational Factor
Concerning the operation of the aircraft
a) Flight indiscipline – a contributor
On several occasions during the flight, the pilots failed to comply with the norms and regulations in force, such as the sections 91.167 and 91.205 of the RBHA 91, the Pilot Operating Handbook and FAA Approved Airplane Flight Manual, and the Lei do Aeronauta (Law of the Aeronaut, Law nº 7.183 of 5 April 1984).
b) Training – undetermined
Before the ditching, the pilot unlocked the rear door of the aircraft and, then, failed to instruct the passengers as to the opening of the emergency exit. This fact shows a probable deviation in the process of training previously received by the captain, since the procedure prescribed for the situation was to abandon the aircraft through the emergency exit, which had to be unlocked after the ditching.
c) Piloting judgment – a contributor
At the moment of their decision to proceed non-stop to the destination, there was an inappropriate evaluation on the part of the crew, because they did not consider the hourly consumption until that point, and the malfunction of the fuel capacity indicator did not allow them to know the exact amount of fuel remaining in the tanks.
d) Flight planning – a contributor
There was a mistake on the part of the captain relative to the planning of the flight, since, in addition to a total flight time of 5 hours and 40 minutes, he did not consider the fuel necessary to fly to an alternate airport plus 45 minutes of flight. The captain and the pilot under training made an inappropriate evaluation of the effects brought by the operational conditions along the flight route.

Belly landing on runway 19 after the pilot forgot to lower the landing gear while approaching the airport.
The following contributing factors were identified:
- Probable distraction of the pilot by keeping his attention mainly on the GPS equipment to maintain the flight path and avoid unnecessary engine power adjustments,
- The pilot failed to follow the approach and landing checklist,
- The pilot failed to check the three gear lights on the cockpit panel,
- The pilot performed an unstabilized approach without completing the pre-landing checklist and eventually stabilized the airplane at a height of 500 feet.

Loss of control while in cruising altitude after the aircraft was flying in the vicinity of a multicell with convective activity, due to the combination of the following factors:
• Incorrect appreciation of the evolution of the meteorological conditions en route,
• Inadequate flight planning,
• Self-induced complacency,
• Inadequate risk assessment for meteorological hazards.

Late use of the normal brake systems on part of the crew after landing, causing the aircraft to overran. The captain had the habit of braking the aircraft while using the reverse thrust systems only in order to save the braking systems. Doing so, the use of the normal brakes was delayed.

The accident investigators, taking into account the characteristics of the accident and the evidence collected in the course of the investigation, considered the Human Factor as the reason for this accident, being able to demonstrate convincingly the following causes:
- There was a breach of the provisions in Chapter 4 (flight operations policies), paragraph 6 (sterile cabin) of the Operations Manual of the airline due to carrying out activities that were not related to the conduct of the flight.
- Lack of situational awareness of the Flight Instructor, the observer pilot and the first officer.
- The captain performed other duties, adding to the duties already being accomplished in his role as a flight instructor.

The Board of Inquiry estimated that the probable cause of this accident was the crew's decision to continue the approach and landing without carrying out the procedures (ABNORMAL AND EMERGENCY PROCEDURES) established by Embraer in the Quick Reference Handbook when a malfunction occurred with the slat/flap system, resulting in a wrong approach configuration.
The following findings were identified:
- The slats were inoperative during the approach and the crew performed five trouble shooting without success,
- Despite this situation, the crew decided to continue the approach, failed to follow the approach checklist and failed to input the reference speed and distance for landing according to circumstances,
- The aircraft landed too far down the runway, about 880 metres past the runway 35 threshold,
- The braking action was low because the runway surface was wet,
- In normal conditions, with flaps down in second position and slats out, the landing reference speed was 119 knots with a landing distance of 880 metres,
- Because the slats were inoperative, the landing reference speed should be 149 knots and a landing distance of 1,940 metres was needed,
- The aircraft passed over the runway threshold at a height of 50 feet and at an excessive speed of 163,8 knots,
- Spoilers were activated 9 seconds after touchdown, 950 metres after the runway threshold,
- Reverse thrust systems were activated 1,280 metres after the runway threshold,
- The crew started to use brakes 2,300 metres after the runway threshold (runway 35 is 3,125 metres long), with the antiskid system activated,
- Due to an excessive approach speed (15 knots above Vref), a too long flare and a too late application of the brake systems, the aircraft could not be stopped within the remaining distance,
- The slats malfunction was the consequence of the failure of several actuators which did not support negative temperatures met during the last flight,
- Since last July 19, the slats failed 53 times on this aircraft, six times during the approach and 47 times in flight,
- The crew failed to initiate a go-around procedure.