South America

Double engine failure in flight due to fuel starvation, forcing the crew to attempt an emergency landing in trees.
The following contributing factors were identified:
- Recurrent failures on the ground and in flight of the aircraft fuel quantity indicators, a situation that was maintained because the Maintenance Programme did not include an inspection and calibration of the fuel quantity gauges.
- Initiating the flight with a fuel indication system inoperative.
- Complacency on part of the crew who decided to continue the flight by having an aerodrome nearby after the first engine failure.

The aircraft landed on the water with the landing gear in the down position.
Contributing factors:
- Attitude – a contributor
Failure to comply with the checklist during the pre-flight inspection and the flight itself favored the landing with inadequate configuration. This attitude may have been triggered by the pilot's confidence in his operational capability, because of his long experience in aviation.
- Flight indiscipline – a contributor
Failure to comply with the checklist indicated, in addition to the low level of situational awareness, a low level of concern for the safe conduction of the flight by failing to follow basic procedures set forth in the manufacturer's manuals and current regulations.
- Piloting judgement – a contributor
The pilot's choice not to use the checklist during the flight phases revealed an inadequate evaluation of parameters related to the operation of the aircraft. Improper compliance with the items in the Pre-Flight Inspection Sheet prevented the AMPHIB PUMP 1 and 2 circuit breakers from being rearmed.
- Aircraft maintenance – a contributor
After performing the test of landing gear extension and retraction by the emergency system, the AMPHIB PUMP 1 and 2 circuit breakers were not rearmed, being the aircraft delivered to fly in this condition. The setting recorded on the AIRSPEED switch of the landing gear position warning system computer demonstrated that the scheduled speed of 74kt was not in accordance with the recommended in the 9600-1A installation manual of Wipaire Inc. in its revision G.
- Memory – undetermined
The AMPHIB PUMP 1 and 2 circuit breakers were found disarmed after the occurrence, indicating that, after the completion of the maintenance service, the executor of the tasks probably forgot to comply with the procedures for reconfiguring the aircraft. In addition, it is possible that the pilot's automatism in relation to his way of carrying out the air operations, without the use of the checklist, has prevented the correct perception of the circuit breakers condition and the erroneous positioning of the landing gear.
- Perception – a contributor
The accomplishment of the landing on the water with the aircraft in inadequate configuration for the situation denotes a decrease in the level of situational awareness of the pilot, considering that the necessary factors and conditions for the safety of the operation were not observed.

The pilot flew a non-standard traffic pattern very low and very close to the runway. The excessive and extreme fight manoeuvres to position the aircraft for the landing resulted in a loss of aircraft control.
Contributory Factors:
The pilot’s failure to operate in accordance with established standard operating procedures when approaching the runway to land.

Loss of control during climb due to the combination of the following factors:
- The particular characteristics of the aircraft;
- The attention required by the transponder as it is not displayed by air traffic control;
- The detour of the planned flight at the request of the inspection department of air traffic;
- Aircraft trajectory management with autopilot switched off;
- The pilot's limited experience in instrument flight conditions. In addition, the absence of additional instruction in the aircraft type (due to the lack of specific regulations) can be considered a contributing factor, according to the probable scenario described above. In addition, the research identified the following elements with potential impact in operational safety:
- Absence of the TAWS system on the aircraft in non-conformity with the established RAAC 91;
- Lack of effective means to enable the flight plan office to quickly determine whether an aircraft has operating restrictions;
- Shortcomings in the training of staff in the units ATS and SAR in search and rescue.

The following findings were identified:
- Inappropriate decision by the aircraft operator to rush the aircraft's initial route to an aerodrome unknown to the company, not appropriate to the type of aircraft and not authorised in its Operating Specifications, without at least a proper risk assessment.
- Inadequate crew decision to accept and decide to proceed to an unknown aerodrome, without due knowledge of its characteristics, without prior experience or training in aerodrome operation and without at least a risk assessment.
- A side runway excursion, from 24 metres from the threshold of runway 25, as a result of a probable unstabilised approach resulting in an off-axis landing.
Contributing factors:
- Inefficient planning and supervision of operations by the aircraft operator, by scheduling the operation to an unknown airfield.
- Failure of the company to comply with the contents of the Dispatch Manual and General Operations Manual, in relation to the procedures that must be complied with before operating new routes, new airports or special airports, in aspects such as route analysis, runway analysis, risk management and crew requirements.
- Ignorance of the Tarapacá runway by the crew.