Acre

Loss of control after landing after the crew selected the power levers on 'ground fine pitch', combined with the failure of the antiskid system due to poor maintenance. The operator was facing enormous financial difficulties which affected the motivation of the maintenance, flight and cabin crew, which was considered as a contributing factor.

Poor approach configuration on part of the flying crew who continued the approach after passing the MDA at 1,150 feet while the aircraft was not stabilized and the crew did not establish a visual contact with the obstacles on short final. The following contributing factors were identified:
- Following the first impact with trees, branches and pieces of wood entered the engines, causing a loss of power followed by a loss of speed and altitude,
- Complacency on the part of the crew,
- Pressure and stress,
- Visual perception issues,
- Violation of the standard operating procedures,
- Loss of situational awareness,
- Lack of crew resources management,
- Poor approach and landing planning,
- Poor weather conditions,
- Relative low experience of the copilot.

The exact cause of the accident could not be determined with certainty. However, it is believed that the accident was the consequence of a controlled flight into terrain after the crew continued the approach in poor weather conditions and descended below the MDA until the aircraft, in a flaps and gear down configuration, impacted ground. The following contributing factors were identified:
- A difference of 70 feet in the settings was noted between both pilot's altimeters,
- Poor crew coordination,
- Complacency on part of the flying crew caused several deviations from procedures during the approach,
- Lack of crew resources management,
- The crew failed to check the altitude during the final stage of the approach,
- Poor weather conditions.

The following findings were identified:
- It is likely that the pilot did not use the controls properly to maintain an adequate control of the airplane in a single-engine configuration while the airplane was operated within weight and balance limits,
- The left propeller retainer had been replaced by similar but not original equipment, using glue to ensure its tightness, which was non compliant with the engine manufacturer's procedures,
- The aircraft maintenance documents were not kept up to date by the operator,
- Poor flight preparation on the part of the pilot who did not notice that the maintenance documents were not up to date,
- The operator was not compliant with the current Brazilian Civil Aviation Authority legislation.

It was determined that the evening prior to the accident, the aircraft suffered an incident upon landing at Feijó Airport. Upon landing the copilot inadvertently mishandled the engines. Reverse pitch was not applied. Directional control was lost and the left main landing gear ran off the side of the runway. The airplane came to rest 40 metres past the runway end. It was towed to the ramp and the captain conducted an inspection of the airplane. As nothing wrong was noticed, the crew decided to continue the flight after the company base was notified of the occurrence. At the time of the accident, the crew was anxious about the event that occurred the preceding evening and the captain's attention was distracted. Thus, there was a higher level of stress in the cockpit at the time of the accident and the copilot did not want to be the PIC for the second leg due to anxiousness. As the right engine was totally destroyed by a post crash fire, it was not possible to determine the exact cause of its malfunction. Poor weather conditions, poor flight planning and insufficient control inputs on the rudder were considered as contributing factors.

The following findings were reported:
a. Human Factor
(1) Physiological Aspect
- There was no evidence of this aspect contributing to the occurrence of the accident.
(2) Psychological Aspect - Contributed
- The psychological aspect contributed through the generation of a high level of anxiety to perform the landing and in the diversion of the focus of attention during the approach manoeuvres to land.
- The psychological aspect was influenced by the activation of the smoke alarm which generated an increase in the workload on board.
b. Material Factor
- There were no indications that this factor contributed to the accident.
c. Operational Factor
(1) Deficient Instruction
- Although the instruction was carried out in accordance with what the standards recommend, the failures that contributed to the accident are characteristic of lack of experience in facing abnormalities simultaneously with the maintenance of flight control. Such failures could be avoided with more adequate simulator instructions and training involving the cockpit management aspects.
(2) Poor Maintenance - Undetermined .
- It was not possible to determine the cause of the activation of the 'Aft Cargo Smoke' alarm and whether the maintenance services contributed to this occurrence.
(3) Deficient Cockpit Coordination
- Inadequate performance of the duties assigned to each crew member. The procedures foreseen for the execution of descent by instrument have been modified and some have been deleted depending on the appearance of a complicator element (smoke alarm).
(4) Influence of the environment
- The dark night contributed to the creation of the 'black hole' phenomenon, or 'background figure', making it difficult to perceive external references for a possible identification of the vertical distance of the aircraft from the ground.
(5) Deficient Oversight
- The supervision, at cockpit level, contributed to the accident by the inadequate management of the resources available for the flight in the cockpit.
- Company level supervision contributed to the accident by not identifying the need for cockpit management training and providing it to the crew involved.
- Supervision, at company level, was also inadequate when climbing to the same mission, two pilots unfamiliar with the airplane to be used and in night operation.
(6) Other Operational Aspects
- The failure to comply with several 'Callouts', the non-use of the radio altimeter and the inadequate use of the 'altitude alert', as an aid to the accomplishment of the descent procedure, contributed to the occurrence of the accident.

Failure of both engines on final approach due to fuel exhaustion following three unsuccessful approaches. The following contributing factors were reported:
- Poor weather conditions,
- Poor visibility,
- Poor flight planning,
- Lack of Company assistance,
- Operational deficiencies,
- Infrastructures deficiencies.

Refueling directly from the trucks without allowing sufficient time for the fuel to settle.