South America

Wrong approach configuration on part of the crew. Execution of the landing procedure on runway 20 despite the fact that aircraft was unstable on approach. At runway threshold, the aircraft altitude was too high and its speed upon touchdown was excessive (132 knots). The airplane touched down 562 metres past the runway threshold, well beyond the touchdown zone. All brakes systems were activated but the upper right thrust reverser deployed and retracted shortly later due to technical reasons, which was considered as a contributory factor. The following factors also contributed to the mishap:
- Poor techniques used by the pilot-in-command on approach and after touchdown,
- Deviation from standard operating procedures (SOP),
- Non-adherence to published procedures,
- No reaction or corrective action to the EGPWS alarm.

The following findings were identified:
- The external tyre on the right main gear deflated during the takeoff roll,
- The crew retarded the power levers and deployed the spoilers,
- The crew did not use the parachute, judging the relative low speed and thinking this was an optional equipment,
- Technical analysis on the right main gear revealed that the six bolts on the external wheel torque were approximately 90% lower than foreseen, which may contributed to the tyre deflection.

The pilot continued the approach in low visibility and let the aircraft descending below the minimum safe altitude. At the time of impact, the aircraft was 10° off track (017° radial) for a runway 20 approach in IMC. Consequently, investigators feel that the accident was caused by a controlled flight into terrain (CFIT). Poor efficiency in procedures execution on part of the pilot by executing an approach in IMC with a twin engine aircraft was considered as a contributory factor, and his relative low experience on type.

The following findings were identified:
- Weather conditions made it difficult for the crew to locate the runway;
- The crew failed to follow the emergency procedures and was unable to keep the aircraft level;
- The captain did not feather the left propeller, which resulted in increased drag and reduced aircraft speed;
- The engine maintenance did not meet the engine manufacturer's requirements;
- No technical overhaul of the left engine had been carried out despite the fact that the 12-year calendar limit set by the manufacturer had been exceeded;
- A nipple mounted on the left propeller governor was not intended for aeronautical use;
- The poor seal caused by the improper connection allowed the pressure to drop, resulting in a loss of power on the left engine;
- Poor organizational culture by the operator, which compromised the safety of the operation;
- The company did not have an effective supervision program;
- Poor judgment on part of the captain;
- Poor aircraft maintenance.

The following findings were identified:
- The crew considered the operation at Angra dos Reis Airport as unsafe, but operated the aircraft at that airport several times due to pressures from the aircraft's owner,
- The landing was completed with a tailwind component and a high aircraft weight, without considering the possibility to use runway 28, which demonstrated a poor assessment of the existing landing conditions,
- The relative short landing distance available, less than one km,
- The possible pressure exerted by the owner to carry out the flights, as well as the need to maintain the job or the professional image, may have contributed to the complacency behavior of the crew on the issues that lead to the operation of aircraft under conditions below acceptable safety standards,
- Poor flight planning,
- The relative low experience of the crew on this type of aircraft.

The accident occurred after the crew suffered a loss of situational awareness while descending into IMC conditions.