Airport (less than 10 km from airport)

The cause of the crash of BAe-125-800B RA-02807 during the ILS approach procedure at night, in weather conditions that met ICAO CAT I, was the failure to take timely action by the crew to carry out a missed approach, or divert to an alternate, when the ground could not be seen while descending below decision height during a transition to visual flight, and the lack of a proper response and action required when the TAWS alarm repeatedly sounded, which led to the collision of the aircraft with obstacles (forest) and land in a controlled flight (CFIT), its destruction and death of people on board.

Contributing factors were:
- Deficiencies in the type of retraining and training of the flight crew, especially in the use of automatic flight modes, and flight director;
- Erroneous actions of the captain, which led to an execution of the approach with the wrong ILS frequency set on the left set;
- Lack of preparation of the commander of the plane for an approach in weather conditions that meet CAT I ICAO.
Values of meteorological conditions in the flight log were in most cases were falsified;
- Poor communication and crew resource management (CRM) of the flightcrew;
- Poor control of the level of training of the crew by the airline's management and lack of organization in the airline's flight operations;
- Psychological characteristics of the pilots, unrecorded in the formation of the crew and, possibly, reduced efficiency of the captain in a stressful situation because of chronic ischemic heart disease with coronary artery problems, which was not detected when passing aviation medical checks.

A total loss of engine power during a night approach for undetermined reasons.

The Investigation identified the following Causes:
(a) the departure of the No. 4 engine core cowls;
(b) the consequent disconnection of No. 4 engine EPR Pt7 flex line;
(c) the probable inappropriate crew response to the perceived No. 4 engine power loss;
(d) the Aircraft entering into a stall after the published maximum bank angle was exceeded; and
(e) the Aircraft Loss of Control (“LOC”) that was not recoverable.

Contributing Factors to the Accident were:
(a) the Aircraft was not properly maintained in accordance with the Structure Repair
Manual where the cowls had gone through multiple skin repairs that were not up to
aviation standards;
(b) the Operator’s maintenance system failure to correctly address the issues relating to the No. 4 engine cowls failure to latch issues;
(c) the failure of the inspection and maintenance systems of the maintenance organization, which performed the last C-Check, to address, and appropriately report, the damage of the No. 4 engine cowls latches prior to issuing a Certificate of Release to Service;
(d) the Operator’s failure to provide a reporting system by which line maintenance personnel report maintenance deficiencies and receive timely and appropriate guidance and correction actions;
(e) the Operator’s quality system failure to adequately inspect and then allow repairs that were of poor quality or were incorrectly performed to continue to remain on the Aircraft; and
(f) the SCAA safety oversight system deficiency to adequately identify the Operator’s chronic maintenance, operations and quality management deficiencies.

After the flight was airborne from BIKF, the flight was restricted by ATC to cruise at FL200 instead of FL280. The lower flight altitude and the power setting used resulted in a reduction of the final reserve to approximately zero minutes. At that time the commander was not concerned about the final reserve because the flight to BGBW was only a two hours flight and as the aircraft before take-off from BIKF had fuel for more than three hours and 40 minutes of flight. During the approach to BGBW the flight never came below the clouds and was in IMC during the entire final approach. The most likely cause was that the aircraft was not following the NDB DME 07 approach procedure descent profile. Consequently the commander did not get visual contact during the approach and he had to make a missed approach. During the diversion to the alternate aerodrome, BGSF the flight was altitude restricted by ATC to FL190. One engine was intentionally stopped during the diversion to BGSF. The consequence was a reduction of the aircraft range. A shallow descent was initiated approximately 57 minutes before ETA over BGSF. The shallow descent profile did consume more fuel than a steeper descent profile. The commander decided to make a precautionary landing in the terrain. The aircraft was destroyed during the landing attempt on the rugged and bumpy surface of the icecap.

Technical or medical problems could not be ruled out according to Dutch Safety Board. However, it was considered likely that the pilot suffered from spatial disorientation.
Factors were:
- the fact that the autopilot disengaged;
- the high work load following loss of autopilot, during a single-pilot flight;
- the lack of training and experience on advanced aircraft like the PC-12 in manually flying the aircraft in IMC in a non-normal situation.

Engine failure for unknown reasons.

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.