South America

The most probable cause for the occurrence of the accident was the malfunction of the centralized crew warning system (CCAS/CAC) with erroneous activation of the flight loss of lift warning system.
The following contributing factors were identified:
- Poor crew resources management,
- Loss of situational awareness,
- Inadequate coordination during the decision-making process to deal with abnormal situations in flight,
- Ignorance of the loss of lift warning system.
- Inadequate handling of flight controls.

The following factors were identified:
- During the approach, the flight crew's attention was focused on the characteristics of the geographical relief and presence of birds, reducing their awareness as to the maintenance of the approach slope.
- The group culture of maintaining a low angle of approach led the crew to choose the runway aspect instead of the VASIS as a reference for the approach, making them susceptible to various types of spatial illusion.
- Taking into account copilot's report that he was not succeeding in correcting the aircraft glide path relative to the runway, one may suppose that he was not applying the appropriate amplitude for such correction.
- The physical characteristics of the runway 15 (the active one) contributed to a wrong perception of the ideal glide path. The pronounced acclivity of the runway, its width (narrower than the runways on which the crew was accustomed to operate), and the low terrain near the threshold, caused in the pilots a perception that they were above the ideal approach slope, leading them to seek correction, which resulted in an angle of approach below the ideal one.
- For the flight in question, the company chose two pilots who had never operated in SBQV. A crewmember with previous experience in the locality would have a higher level of awareness in relation to the specific characteristics of the aerodrome.
- No company publications were found that could provide the pilots with guidance on the specifics of SBQV, capable of helping with the management of the risks associated with the operation in that aerodrome.

Execution of the flight below the angle of approach, due to a misjudgment of the crew, believing to be much higher, leading the aircraft to fly a typical trajectory of a 'black hole' illusion, which was experienced during the night-time approach to a runway with low contrast surrounded in bright focused lights, aggravated by bad weather of heavy rain.

Loss of control during takeoff following the crew's decision to perform the operation outside of the procedures established in the flight manual. The overconfidence of the crew as well as the operation of both engines at low regime were considered as contributing factors.

An error in the assembly was detected in the left generator, which interfered with the D+ terminal signal sent to the voltage regulator. Due to a voltage drop, some of the instruments lost their functionality. The following contributing factors were identified:
- The crew did not follow the emergency procedures;
- The crew decided to return to land at Santos Dumont Airport without considering that the runway length was less than the length required for an emergency landing;
- The speed of the aircraft while passing over the runway threshold was 25 knots above the reference speed;
- The pilots were unable to engage the spoilers or the thrust reversers;
- Wrong attitude from the captain;
- Overconfidence of the crew;
- Emotional load due to an emergency situation;
- Poor assessment of the situation due to high stress associated with decreased situational awareness;
- Poor crew coordination;
- Lack of crew resource management;
- Poor judgment;
- Lack of procedures on the part of the operator.

One of the engine failed during initial climb for unknown reasons.

Controlled flight into terrain after the crew descended too low in IMC conditions. The following contributing factors were identified:
- Visibility was below minimums,
- The crew continued the descent until the aircraft impacted ground and failed to initiate a go-around procedure,
- A probable crew fatigue,
- It is possible that the crew suffered optical illusions,
- Overconfidence on part of the captain,
- The captain did not request any assistance from the copilot during the approach procedure,
- Inexperienced, the copilot did not interfere despite dangerous flight conditions,
- Poor organizational culture,
- Deficiencies in crew training,
- Lack of crew discipline,
- Poor flight planning,
- Lack of supervision on part of the operator,
- The copilot was inexperienced on this type of aircraft.