Airport (less than 10 km from airport)

The investigation determined the inadequate action of the flight engineer, consisting in early and uncommanded landing gear retraction, as a cause of the accident.
Contributing factors to the accident were:
1. Inadequate crew recourse management and insufficient experience in cooperation and coordination between crewmembers.
2. Start of aircraft rotation at low speed and with fast elevator movement to 17˚, which resulted in:
Lifting the aircraft sufficiently to close the WOW switch and allow the retraction of the landing gear at the speed not sufficient for the climb.
Providing misleading information to FE about the aerodynamic status of the aircraft.
3. Inadequate adjustment of the WOW switch, which allowed the gear retraction to be activated before the aircraft was airborne. The position of the landing gear selector on the central console is not considered as a contributing factor to the accident. However, investigation finds necessary to point it out as a safety concern, specifically in situations, where crewmembers are trained and/or used to operate the aircrafts with gear selector location according to the EASA Certification Standards CS-25. Positioning of the gear lever to the location which is compliant to EASA document CS-25, would create additional safety barrier to avoid similar occurrences, specifically in aircrafts where landing gear is operated by FE.

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.

Loss of control on final approach due to the movement of several passengers in the cabin, panicked by the presence of a crocodile.

- In violation of the airline's flight operation manual the captain attempted the approach to Yichun below required visibility. The airport reported 2800 meters of visibility while the manual required 3600 meters of visibility to begin the approach
- In violation of regulations by the Civil Aviation Authority the crew descended below minimum descent altitude although the aircraft was operating in fog and visual contact with the runway had not been established
- Despite the aural height announcements and despite not seeing the runway the crew continued the landing in the blind without initiating a go-around resulting in impact with terrain
Contributing factors were:
- The airline's safety management is insufficient:
* part of the flight crew arbitrarily implement the company's operations manual as the company does not follow up outstanding problems. Records suggest frequent deviations from approach profiles, i.e. deviation above or below glide slopes, excessive rates of descents and unstable approaches
* crew rostering and crew cooperation: Each of the crew was flying into Yichun for the first time despite the known safety risks at the airport, the communication and cooperation within the crew was insufficient, the crew members did not monitor each other in order to reduce human errors
* the airline's emergency training did not meet requirements, in particular the cabin crew training did not provide for hands on training on E190 cabin doors and overwing exits. Alternate means by the airline did prove ineffective and did not provide the quality China's Civil Aviation Authority requires thus leaving cabin crew unprepared to meet required cabin crew emergency response capabilities
- Parent company's Shenzhen Airlines oversight insufficient
* Shenzhen Airlines, after having taken over Henan Airlines in 2006, did not provide sufficient funding and technical support affecting the stability and safety of staff and quality management
* Air China, holding stock into Shenzhen Airlines, installed a safety supervisor but failed to address the safety management issues with Shenzhen and Henan Airlines
- No supervision by China's Civil Aviation Authority
* the license to operate the flight from Harbin to Yichun was granted without route validation and without safety management in violation of regulations
* to solve the lack of cabin crew flight attendants were certified although not meeting the relevant requirements for air transport operations
* the regional office of the Civil Aviation Authority did not communicate to their superiors that they had approved the domestic operation of the route from Harbin to Yichun permitting non-standard procedures
- China's Civil Aviation Authority safety management loopholes.

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.

Controlled flight into terrain after the crew descended in IMC conditions below the glide without visual contact with the ground. The following contributing factors were identified:
- The failure of the crew to initiate a go-around procedure,
- Incorrect weather forecast with regards to cloud ceiling, visibility and severe weather (fog),
- Inaccurate information about the actual weather on the glide path at the Middle Marker with course 117°, radioed to the crew 40 minutes before the accident.

The board president found clear and convincing evidence that the cause of the mishap was pilot error. The pilot violated regulatory provisions and multiple flight manual procedures, placing the aircraft outside established flight parameters at an attitude and altitude where recovery was not possible. Furthermore, the copilot and safety observer did not realize the developing dangerous situation and failed to make appropriate inputs. In addition to multiple procedural errors, the board president found sufficient evidence that the crew on the flight deck ignored cautions and warnings and failed to respond to various challenge and reply items. The board also found channelized attention, overconfidence, expectancy, misplaced motivation, procedural guidance, and program oversight substantially contributed to the mishap.

Primary Cause Factor:
- Failure of the flight crew to discontinue the approach when deteriorating weather and their associated hazards to flight operations had moved into the airport (Human Factor)
Contributory Factor:
- The adverse weather condition affected the judgment and decision-making of the PIC even prior to the approach to land. With poor weather conditions being encountered, the PIC still continued the approach and landing. (Environmental Factor)
Underlying Factor:
- As a result of the bounced landing, several cockpit instruments were affected including both transponders on board. One of the nosewheels was detached and all the landing gears could not be retracted. Further, the integrity of the structure may have been affected and chance airframe failure was imminent. With all of these conditions, the Captain still opted to request for a priority landing when emergency landing was needed.