South America

The accident was caused by the loss of control of the airplane while performing the tailwind leg through the channel between the islands of Robinson Crusoe and Santa Clara to an estimated height of 650 feet or less, during the circuit approach to Runway 32 in a very low trajectory (with little height difference above the runway), where very adverse airflow conditions were found, including wind shear, which exposed the crew to extreme flight conditions.
Adverse airflow conditions were the results of a combination of different factors, including:
- Very unstable atmosphere, with strong turbulence and possibly eventually powerful down gusts arising from the presence of open cells after a front passed,
- The presence of the two counter-rotating vortexes in the Santa Clara Island downwind wake,
- The presence of strong and gusty crosswinds that were very variable in strength and direction in a very short time.

The probable cause of the accident was that the aircraft touched down approximately 4,700 feet beyond the runway threshold, some 2,700 feet from the end of the runway, as a result of the Captain maintaining excess power during the flare, and upon touching down, failure to utilize the aircraft’s full deceleration capability, resulted in the aircraft overrunning the remaining runway and fracturing the fuselage.
Contributory Factors:
The Flight Crew’s indecision as to the execution of a go-around, failure to execute a go-around after the aircraft floated some distance down the runway and their diminished situational awareness contributed to the accident.

Human Factors
Medical Aspect
- Anxiety
The perception of danger especially by the first officer affected the communication between the pilots and may have inhibited a more assertive attitude, which could have led to an emergency landing on the beach, minimizing the consequences of the accident.
Psychological Aspect
- Attitude
Operational decisions during the emergency may have resulted from the high confidence level, that the captain had acquired in years of flying and experience in aviation, as well as the captain's resistance to accept opinions different to his own.
- Emotional state
According to CVR recordings there was a high level of anxiety and tension even before the abnormal situation. These components may have influenced the judgment of conditions affecting the operation of the aircraft.
- Decision making
The persistence to land on runway 36 during the emergency, even though the first officer recognized the conditions no longer permitted to reach the airport, reflects misjudgment of operational information present at the time.
- Signs of stress
The unexpected emergency at takeoff and the lack of preparation for dealing with it may have invoked a level of stress with the crew, that negatively affected the operational response.
Psychosocial Information
- Interpersonal relations
The historical differences between the two pilots possibly hindered the exchange of information and created a barrier to deal with the adverse situation.
- Dynamic team
The present diverging intentions of how to proceed clearly show cooperation and management issues in the cockpit. This prevented the choice of best alternative to achieve a safe emergency landing when there were no options left to reach the airport.
- Company Culture
The company was informally divided into two groups, whose interaction was impaired. It is possible that this problem of interaction continued into the cockpit management during the in flight emergency, with one pilot belonging to one and the other to the other group.
Organizational Information
- Education and Training
Deficiencies of training provided by the operator affected the performance of the crew, who had not been sufficiently prepared for the safe conduct of flight in case of emergency.
- Organizational culture
The actions taken by the company indicate informality, which resulted in incomplete operational training and attitudes that endangered the safety.
Operational Aspects
According to data from the flight recorder the rudder pedal inputs were inadequate to provide sufficient rudder deflection in order to compensate for asymmetric engine power.
The values of side slip reached as result of inadequate rudder pedal inputs penalized the performance of the aircraft preventing further climb or even maintaining altitude.
In the final phase of the flight, despite the airspeed decaying below Vmca, despite continuous stall warnings and despite calls by the first officer to not hold the nose up in order to not stall the captain continued pitch up control inputs until the aircraft reached 18 degrees nose up attitude and entered stall.
- Crew Coordination
The delay in retracting the landing gear after the first instruction by the captain, the instruction of the captain to feather the propeller when the propeller had already been feathered as well as the first officer's request the captain should initiate the turn back when the aircraft was already turning are indicative that the crew tasks and actions were not coordinated.
Emergency procedures provided in checklists were not executed and there was no consensus in the final moments of the flight, whether the best choice (least critical option) was to return to the runway or land on the beach.
- Oblivion
It is possible in response to the emergency and influenced by anxiety, that the crew may have forgotten to continue into the 3rd segment of the procedure provided for engine failure on takeoff at or above V1 while trying to return to the airfield shortly after completion of the 2nd segment while at 400ft.
- Pilot training
The lack of training of engine failures on takeoff at or above V1, similar as is recommended in the training program, led to an inadequate pilot response to the emergency. The pilots did not follow the recommended flight profile and did execute the checklist items to be carried out above 400 feet.
- Pilot decisions
The pilots assessed that the priority was to return to land in opposite direction of departure and began the turn back at 400 feet, which added to the difficulty of flying the aircraft. At 400 feet the aircraft maintained straight flight and a positive rate of climb requiring minor flight control inputs only, which would have favored the completion of the emergency check list items in accordance with recommendations by the training program.
After starting the turn the crew would needed to adjust all flight controls to maintain intended flight trajectory in addition to working the checklists, the turn thus increased workload. It is noteworthy that the remaining engine developed sufficient power to sustain flight.
- Supervision by Management
The supervision by management did not identify that the training program provided to pilots failed to address engine failure above V1 while still on the ground and airborne.
It was not identified that the software adopted by the company to dispatch aircraft used the maximum structural weight (6,600 kg) as maximum takeoff weight for departures from Recife.
On the day of the accident the aircraft was limited in takeoff weight due to ambient temperature. Due to the software error the aircraft took off with more than the maximum allowable takeoff weight degrading climb performance.
Mechanical Aspects
- Aircraft
Following the hypothesis that the fatigue process had already started when the turbine blade was still attached to the Russia made engine, the method used by the engine manufacturer for assessment to continue use of turbine blades was not able to ensure sufficient quality of the blade, that had been mounted into position 27 of the left hand engine's Gas Generator Turbine's disk.
- Aircraft Documentation
The documentation of the aircraft by the aircraft manufacturer translated into the English language did not support proper operation by having confusing texts with different content for the same items in separate documents as well as translation errors. This makes the documentation difficult to understand, which may have contributed to the failure to properly implement the engine failure checklists on takeoff after V1.
An especially concerning item is the "shutdown ABC (Auto Bank Control)", to be held at 200 feet height, the difference between handling instructed by the checklist and provided by the flight crew manual may have contributed to the non-performance by the pilots, aggravating performance of the aircraft.

During a flight of transport of values, in the phase of cruise, a smoke emergency appeared in the cockpit, that when not being able to be controlled, derived in a landing of emergency by precaution in a nonprepared field, which resulted without apparent damages to the aircraft, triggering later a fire and the almost total destruction of the same, due, very probably, to an electrical failure that originated the fire.

It is possible that the pilot applied the flight controls inappropriately when the aircraft returned to the runway, making it impossible to maintain direction. After the 'door warning' light activated, the pilot made the decision to land when, according to the manufacturer, the situation did not require such immediate action but a continuation of the climb. It is possible that the pilot's training was not adequate or sufficient, because after the 'door warning' light came ON and the abnormal vibrations, the pilot carried out a procedure different from the one recommended by the manufacturer, and placed the plane in an irreversible condition.

During a commercial, domestic passenger flight, while cruising, the crew lost control of the aircraft, which uncontrollably impacted the ground due to severe ice formation caused by the following factors:
- Entering an area with icing conditions without adequately monitoring the warning signals from the external environment (temperature, cloudiness, precipitation and ice accumulation) or the internal (speed, angle of attack), which allowed for prolonged operations in icing conditions to take place.
- Receiving a forecast for slight icing - given that the aircraft encountered sever icing conditions - which led to a lack of understanding regarding the specific meteorological danger.
- Inadequately evaluating the risks, which led to mitigating measures such as adequate briefing (distribution of tasks in the cockpit, review of the de-icing systems, limitations, use of power, use of autopilot, diversion strategy etc.) not being adopted.
- Levels of stress increasing, due to operations not having the expected effects, which led the crew to lose focus on other issues.
- Icing conditions that surpassed the aircraft's ice protection systems, which were certified for the aircraft (FAR 25 Appendix C).
- Inadequate use of speed, by maintaining the speed close to stall speed during flight in icing conditions.
- Inadequate use of the autopilot, by not selecting the IAS mode when flying in icing conditions.
- Partially carrying out the procedures established in the Flight Manual and the Operations Manual, when entering into areas with severe icing conditions.
- Realizing late that the aircraft had started to stall, because the buffeting that foretells a stall was confused with the vibrations that signify ice contamination on the propellers.
- Activation of the Stick Shaker and Stall Warning at a lower speed than expected in icing conditions.
- Using a stall recovery technique which prioritized the reduction of the angle of attack at the expense of altitude loss, and which was inappropriate for the flight conditions.
- The aileron flight controls reacting in an unusual manner when the aircraft lost control, probably due to the accumulation of ice in the surfaces of these, which made it impossible for the aircraft to recover. The increasingly stressful situation of the crew, which affected its operational decision-making.

The most likely cause of the accident would have been the loss of control of the aircraft when performing the flare, caused by a loss of lift (stall), because the CofG was beyond the rear limit.
The following contributing factors were identified:
- The aircraft was unstable on its longitudinal axis because the CofG was too far aft,
- The cargo was not properly secured in the cabin.