Lake, Sea, Ocean, River

A loss of control in flight for unknown reasons.

The French BEA said in its final report that no technical anomaly to affect significantly the performance of the airplane or its pitch control could be demonstrated. It appears that the pilot had consumed alcohol before the flight and was awake since 0630LT and did not sleep over 20 hours, which could affect his capabilities. In conclusion, the investigation did not determine the cause of the accident, but the following factors may have contributed:
- aircraft's operation with one pilot only,
- absence of regulation does not allow the Civil Aviation Authority to ensure the adequacy of the operational objectives of an operator and its capacity to maintain its activity. This failure could not ensure that the pilot was able to conduct the flight.
- the presence of a flight recorder would probably help to understand the circumstances of the accident with more precision. Important data failed to the investigation, which was not able to identify all possible measures to avoid a similar accident in the future.

Pilot incapacitation, which resulted in the pilot’s inability to maintain airplane control and the airplane’s subsequent ocean impact.

Review of the fuel ticket revealed that the misspelled words; "Top Neclles" was handwritten on it. It was also signed by the pilot. Further review revealed that only 25 gallons had been uploaded to the airplane, and this number had been entered in the box labeled "TOTAL GALLONS DELIVERED". Review of the start reading and end reading from the truck meter also concurred with this amount. Furthermore, It was discovered that the "134 gallons" that the pilot believed had been uploaded to the airplane was in fact the employee number of the fueler that had topped off the nacelle tanks and had entered his employee number on the "FUEL DEL BY:" line. Utilizing the information contained on the fuel ticket, it was determined that the airplane had departed with only 261 gallons of fuel on-board. Review of performance data in the POH/AFM revealed that in order to complete the flight the airplane would have needed to depart with 328 gallons on-board.

The flight crew's failure to maintain adequate airspeed after shutting down the right engine due to an in-flight fire in one of the right augmentors. The failure to maintain airspeed resulted in either an aerodynamic stall or a loss of directional control.

The failure of the seal of the balance tube on the left engine intake manifold, causing a loss of manifold pressure and then a loss of engine power.
Contributing Factor:
- Discrepancies found with the quality control of the maintenance services performed on the aircraft,
- The non-assertive decisions taken during the flight when the emergency occurred.

The following findings were identified:
a) The pilots had valid aeronautical medical certificates;
b) The pilots had valid technical qualification certificates;
c) The aircraft captain had qualification and enough experience for the flight in question;
d) The copilot was under training;
e) The aircraft had a valid airworthiness certificate;
f) The planning of the flight from SBSP to SBBE was done by the pilot in command, who took in consideration an aircraft with a full load of fuel;
g) The flight plan read that the fuel endurance was 7 hours and 30 minutes of flight, for an estimated elapse time of 5 hours and 40 minutes at FL230;
h) When the aircraft was passing over the city of Palmas, State of Tocantins, the pilots decided, in conjunction, to proceed non-stop to the destination, discarding the need to make an intermediate landing for refueling;
i) The aircraft was registered in the passenger transport category (TPP) and was engaged in the transport of a sick person;
j) The fuel quantity indicators and the fuel flow indicators of the aircraft were not showing dependable information;
k) The flight plan for the leg betwren SBSP and SBBE contained information of sick person transportation, but there was no sick person on board;
l) The aircraft made a ditching near the banks of Guajará Bay, at a distance of approximately 1,200 meters from the threshold of runway 06 of SBBE;
m) The passengers and crew were rescued by Brazilian Navy servicemen on duty on the Naval Base of Val de Cans;
n) One of the pilots and both passengers got out uninjured, while the other pilot suffered minor injuries; and
o) The aircraft sustained substantial damage.
Contributing factors:
Concerning the operation of the aircraft
a) Attitude – a contributor
The captain failed to comply with norms and procedures by accepting to fly an aircraft on his day of rest, even knowing that he was to start his on-call duty hours as soon as he landed in SBBE.
He also showed to be overconfident when he decided to fly directly from SBSP to SBBE, trusting the 7-hour fuel endurance of his aircraft and the fuel consumption information displayed by the instruments, even after identifying their malfunction. The pilot under training, in turn, was complacent by accepting and agreeing with the pilot-in-command’s decision, without questioning his calculations or motivations for flying direct to the destination.
b) Motivation – a contributor
The captain was eager to return to SBBE on that same day, because he was supposed to start his on-call duty hours in the air taxi company for which he worked.
c) Decision-making process – a contributor
The captain failed to comply with important aspects concerning the route conditions and aircraft instruments by making a decision to fly directly from SBSP to SBBE.
Psychosocial information
a) Communication – a contributor
There was lack of assertiveness on the part of the copilot since he did not question the captain’s calculations and/or motivations to fly non-stop, when he (the copilot) considered that making a stop for refueling would be safer.
b) External influence – a contributor
The involvement of the captain with activities of another company on that same day, in addition to events belonging to his private life, had influence on his decisions in the initial planning of the flight and during the flight en route.
Organizational information
a) Work organization – a contributor
The company delegated responsibility for the entire planning of the flight to the pilots. Therefore, there was not any interference on the part of the company in the crew’s work day and in the legs defined for the flight.
b) Organizational culture – a contributor
The fact that the company performed an operation for which it was not certified reflected the fragility of an organizational culture which allowed it to perform activities unfavorable to operational safety.
Operational Factor
Concerning the operation of the aircraft
a) Flight indiscipline – a contributor
On several occasions during the flight, the pilots failed to comply with the norms and regulations in force, such as the sections 91.167 and 91.205 of the RBHA 91, the Pilot Operating Handbook and FAA Approved Airplane Flight Manual, and the Lei do Aeronauta (Law of the Aeronaut, Law nº 7.183 of 5 April 1984).
b) Training – undetermined
Before the ditching, the pilot unlocked the rear door of the aircraft and, then, failed to instruct the passengers as to the opening of the emergency exit. This fact shows a probable deviation in the process of training previously received by the captain, since the procedure prescribed for the situation was to abandon the aircraft through the emergency exit, which had to be unlocked after the ditching.
c) Piloting judgment – a contributor
At the moment of their decision to proceed non-stop to the destination, there was an inappropriate evaluation on the part of the crew, because they did not consider the hourly consumption until that point, and the malfunction of the fuel capacity indicator did not allow them to know the exact amount of fuel remaining in the tanks.
d) Flight planning – a contributor
There was a mistake on the part of the captain relative to the planning of the flight, since, in addition to a total flight time of 5 hours and 40 minutes, he did not consider the fuel necessary to fly to an alternate airport plus 45 minutes of flight. The captain and the pilot under training made an inappropriate evaluation of the effects brought by the operational conditions along the flight route.

The total loss of engine power during cruise flight for reasons that could not be determined because the airplane was not recovered. Contributing to the accident was the pilot’s failure to comply with the airplane and engine limitations, and his decision to fly over water beyond power-off gliding distance from shore.

The accident was caused by the loss of control of the airplane while performing the tailwind leg through the channel between the islands of Robinson Crusoe and Santa Clara to an estimated height of 650 feet or less, during the circuit approach to Runway 32 in a very low trajectory (with little height difference above the runway), where very adverse airflow conditions were found, including wind shear, which exposed the crew to extreme flight conditions.
Adverse airflow conditions were the results of a combination of different factors, including:
- Very unstable atmosphere, with strong turbulence and possibly eventually powerful down gusts arising from the presence of open cells after a front passed,
- The presence of the two counter-rotating vortexes in the Santa Clara Island downwind wake,
- The presence of strong and gusty crosswinds that were very variable in strength and direction in a very short time.