Bahia

Contributing factors.
- Control skills – a contributor
The inadequate performance of the controls led the aircraft to make a ramp that was lower than the ideal. This condition had the consequence of touching the ground before the runway’s threshold.
- Attention – undetermined
During the approach for landing, the commander divided his attention between the supervision of the copilot's activities and the performance of the aircraft's controls. Such circumstances may have impaired the flight management and limited the reaction time to correct the approach ramp.
- Attitude – undetermined
The report that the commander took two photographs of the runway and of the Aerodrome with his cell phone, during the wind leg, reflected an inadequate and complacent posture in relation to his primary tasks at that stage of the flight, which may have contributed to this occurrence.
- Communication – undetermined
As reported by the commander, the low tone and intensity of voice used by the copilot during the conduct of callouts, associated with the lack of use of the head phones, limited his ability to receive information, which may have affected his performance in management of the flight.
- Crew Resource Management – a contributor
The lack of proper use of CRM techniques, through the management of tasks on board, compromised the use of human resources available for the operation of the aircraft, to the point of preventing the adoption of an attitude (go-around procedure) that would avoid the accident, from the moment when the recommended parameters for a stabilized VFR approach are no longer present.
- Illusions – undetermined
It is possible that the width of the runway, narrower than the normal for the pilots involved in the accident, caused the illusion that the aircraft was higher than expected, for that distance from the thrashold 11 of SIRI, to the point of influence the judgment of the approach ramp. In addition, the fact that the pilot was surprised by the geography of the terrain (existence of dunes) and the coloring of the runway (asphalt and concrete), may have led to a false visual interpretation, which reflected in the evaluation of the parameters related to the approach ramp.
- Piloting judgment – a contributor
The commander's inadequate assessment of the aircraft's position in relation to the final approach ramp and landing runway contributed to the aircraft touching the ground before the thrashold.
- Perception – undetermined
It is possible that a decrease in the crew's situational awareness level resulted in a delayed perception that the approach to landing was destabilized and made it impossible to correct the flight parameters in a timely manner to avoid touching the ground before the runway.
- Flight planning – undetermined
It is possible that, during the preparation work for the flight, the pilots did not take into account the impossibility of using the perception and alarm system of proximity to the ground that equipped the aircraft, and the inexistence of a visual indicator system of approach ramp at the Aerodrome.
- Other / Physical sensory limitations – undetermined
The impairment of the hearing ability of the aircraft commander, coupled with the lack of the use of head phones, may have interfered with the internal communication of the flight cabin, in the critical phase of the flight.

The following factors were identified:
- Application of the commands - contributed
There was no effective action on the aircraft controls during the final approach to avoid a brutal impact with the ground prior to the runway threshold.
- Adverse weather conditions - undetermined
It is possible that the aircraft was under the effect of the phenomenon known as windshear, which affected the approach profil and the subsequent impact with the ground short of runway.
- Pilot judgement - contributed
The risks of a possible windshear during the final approach were not adequately considered by the pilot. The decision to proceed for the landing, to the detriment of the alternative recommended by experts to perform a missed approach, proved decisive for the development of the accident.

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.

The crew's decision to continue the approach in poor weather conditions following a high motivation to land at destination.
The following contributing factors were identified:
- The crew failed to follow the published procedures,
- The crew did not take the bad weather conditions into consideration and took the decision to land,
- Limited visibility due to rain falls and night,
- Weather conditions affected the perception of the pilots who suffered a loss of situational awareness,
- Poor judgment of the situation and flight conditions on part of the crew,
- The crew continued the approach under VFR mode in IMC conditions,
- The crew carried out an improvised VFR approach via a GPS system,
- Excessive approach speed,
- Poor crew coordination,
- Lack of crew discipline.

The decision of the captain to continue the approach under VFR mode in IMC conditions to an airport that was not suitable for IFR operations. The following contributing factors were identified:
- The lack of ground references may have contributed to the commander's spatial disorientation,
- Although the weather conditions made it impossible to land under VFR conditions, the captain insisted on landing, neglecting IFR procedures,
- The captain ignored the copilot's advice and continued with the approach procedure,
- The captain put the aircraft in an attitude that caused it to stall,
- Poor judgment on part of the captain,
- Despite the implementation of a CRM program, the operator was unable to identify that the captain was violating the published procedures.

Engine failure in flight following a fuel exhaustion. It was determined that the crew failed to prepare the flight properly and did not calculate the fuel consumption correctly. Investigations determined that the crew calculated a fuel consumption of 100 liters per hour while the true consumption was 120 liters per hour. The following contributing factors were identified:
- Overconfidence on part of the crew,
- Poor organisational culture that affected flight safety,
- Poor flight planning,
- The crew failed to feather the propeller following the engine failure, causing drag and contributing to the loss of control at low height.

Loss of control after the crew encountered adverse weather conditions with low level windshear. The following contributing factors were identified:
- Although the operations were carried out in accordance with the regulations in force, the pilots regularly exceeded the flight times and this type of prospecting mission is extremely tiring insofar as it is systematically operated at low altitude without the aid of the autopilot system in a high outside temperature environment, leading to greater than normal physical wear of the pilots,
- Poor flight preparation regarding the probable evolution of the weather conditions,
- The accident occurred in low visibility as the crew was presumably trying to return to his base,
- The accident occurred outside of the intended flight area,
- The flight, which was scheduled to take three hours, was started with an aircraft whose tanks were full (seven hours autonomy), unnecessarily increasing its weight,
- Poor flight planning,
- Non-compliance with standard operator procedures on part of the crew who positioned the flaps in an inappropriate angle to fly over obstacles,
- In the days preceding the accident, two incidents occurred at Paramirim Airport involving the captain, and neither of these two events had been reported to the management of the operator, indicating the absence of an effective control of operations,
- The supervision of crew schedules was poor,
- The operator wanted this type of flight to be carried out in the morning in order to avoid atmospheric turbulence specific to the region, but the crew decided to take off in the afternoon when the conditions were not favorable.

The crew continued the descent under VFR mode in IMC conditions and descended too low to maintain a visual contact with the ground until the aircraft impacted terrain. The following contributing factors were identified:
- Poor crew coordination,
- Lack of visibility,
- The crew failed to follow the published procedures.

It is believed that the engine fire was the consequence of the failure of a fuel burner.

The following findings were identified:
- Failure of the left engine on final approach,
- Possible over-correction on part of the pilot-in-command, causing a loss of control after a full rudder compensation,
- The aircraft was in a flaps and landing gear down configuration and it is believed that the copilot failed to assist the pilot during an emergency situation,
- The distance between the aircraft and the ground was insufficient to expect recovery,
- The crew used the auxiliary fuel tanks during all flight without paying attention to the potential danger of such procedure,
- Lack of crew support and crew training on part of the operator,
- Lack of crew resources management.