Goiás

The pilot intentionally changed his routing for Itapaci where the landing zone was not approved for flight operations. During the landing, the plane struck the ground before the planned zone and crashed. The pilot violated the rules established by the authority.

Contributing factors:
- Attitude – a contributor
The pilot's failure to monitor the fueling showed a complacent attitude regarding the verification of conditions that could affect flight safety. Therefore, the lack of knowledge about the real fuel levels implied the insertion of wrong data and an intermediate landing to check the situation, after its identification.
- Training – undetermined
It is possible that the pilot's little familiarization with the aircraft emergency procedures delayed the identification of the situation and limited his possibilities of action.
- Insufficient pilot’s experience – undetermined
The pilot's little experience on the aircraft may have slowed his ability to recognize the emergency and to perform the actions described in the checklist efficiently.

The following findings were identified:
- The copilot was not certified in the C525 type aircraft,
- The aircraft was above the maximum landing weight limit, but within the balance limit,
- On 13JUN2014, there was a NOTAM in force, informing the prohibition of jet aircraft operation in SWNH,
- The pilot acted incorrectly on the handle of the auxiliary gear control, thinking that he was applying the emergency brake, making the braking of the aircraft impossible.
- The activation of the incorrect lever for the emergency braking of the aircraft was due to insufficient training received by the pilot for the use of the system in question, thus compromising the proper management of the abnormal condition.
- The emergency brake actuator handle of the aircraft was located outside the pilot's sight field, which, together with the lack of knowledge about the correct lever to be activated for emergency braking, favored the pilot's automatic response in triggering the lever that was most adjusted and visually available on the panel - the emergency landing gear drive lever.
- The instruction that the pilot received to operate the Cessna aircraft, model 525 did not emphasize in the theoretical phase the proper use of the emergency brake, nor contemplated training for the use of this system.
- Despite having a lot of experience in aviation, the pilot was little experienced in the aircraft and still did not know basic functionalities like the use of the emergency brake and the engine shutdown through the evacuation checklist procedure.

The following findings were identified:
- Factors, such as obesity and sedentariness, associated with the high workload in the moments preceding the collision with the hill, may have contributed for the task demand to exceed the margins of safety, resulting in wrong decision-making by the pilot.
- Upon facing adverse meteorological conditions and being aware that aircraft which landed before him had reached better visibility in altitudes below 3,500 ft. on the final approach of the VOR procedure, the pilot may have increased his level of confidence in the situation, to the point of descending even further, without considering the risks involved.
- The weather conditions encountered in the final phase of the flight may have aggravated the level of tension in the aircraft cabin to the point of compromising the management of the situation by the pilot, who delegated responsibility for radiotelephony communication to a passenger.
- If one considers that the pilot may have decided to descend below the minimum safe altitude in order to achieve visual conditions, one may suppose that his decision, probably influenced by the experience of the preceding aircraft, was made without adequate evaluation of the risks involved, and without considering the option of flying IFR, in face of the local meteorological conditions. In addition, the pilot’s decision-making process may have been compromised by lack of information on Mount Santo Antonio in the approach chart.
- The primary radar images obtained by Anápolis Control (APP-AN) indicated the presence of thick nebulosity associated with heavy cloud build-ups on the final approach of the VOR procedure. Such meteorological conditions influenced the occurrence, which culminated in the collision of the aircraft with Mount Santo Antônio, independently of the hypotheses raised during the investigation.
- The final approach on the course 320º, instead of 325º, made the aircraft align with the hill with which it collided.
- Mount Santo Antonio, a control obstacle on the final approach in which the collision occurred, was not depicted in the runway 32 VOR procedure approach chart, in discordance with the prescriptions of the CIRTRAF 100-30, a fact that may have contributed to a possible decrease of the situational awareness.

Failure of both engines in flight due to fuel exhaustion. The following contributing factors were identified:
- Poor judgment on the part of the pilot who considered that the quantity of fuel present in the tanks before departure was sufficient, which was not the case,
- Poor flight planning on part of the pilot who miscalculated the fuel consumption,
- The pilot failed to follow the procedures related to fuel policy.

The pilot decided to continue the approach in a flapless configuration and at an insufficient speed, which caused the aircraft to stall on short final.

Wrong approach configuration on part of the crew who continued the approach while the aircraft was not properly aligned with the runway centerline.

The following findings were identified:
- It was not possible to determine the contribution of the physiological aspect because the pilot was not found and his license had expired.
- At the critical moment of landing, a state of indecision was triggered in the pilot regarding the procedure to be adopted (landing or going around), impairing its decision-making capacity and causing delay in decision making.
- The pilot did not act adequately on the aircraft controls in order to counteract the action of the crosswind, allowing the aircraft to stand to the right of the approach axis and touch the right side of the runway. Subsequently, he was unable to prevent the left wings from climbing, causing the lower right wing to touch the ground and exit the runway.
- The pilot's decision not to go around immediately when he noticed the first signs of the aircraft's turning tendency, forced by the wind effect and, consequently, having lost full control of the aircraft, contributed to the worsening of the subsequent facts. The pilot acted belatedly when he decided to go around.
- The owner of the aircraft no longer verified that the technical qualification and the Certificate of Physical Capacity of the pilot were up to date for the performance of the air activity, as well as the certificates necessary for the operation of the aircraft. It also went against what prescribes the CTA certification, which establishes two pilots as the minimum crew for the aircraft.
- The left cross wind, associated with the inadequacy of the pilot's controls to counteract it, resulted in the right wing touching the ground, with consequent loss of control of the aircraft.
- The pilot failed to carry out a readaptation flight in the aircraft with a qualified instructor, being for more than three years without flying in the equipment.

Both engines failed 12 minutes apart due to fuel exhaustion. The following contributing factors were identified:
- Fuel tanks were empty,
- The fuel quantity was insufficient to cover the requested flying distance,
- Poor flight preparation and planning,
- Complacency on part of the copilot,
- Wrong decisions on part of the captain,
- Failures in the organization of flights within the operations of the Government of the State of Goiás,
- Miscalculations in fuel consumption.
- Operating an airplane with faulty fuel gauges,
- Failures in monitoring related to flight safety culture,
- Poor crew resources management,
- Poor crew coordination,
- Lack of crew interactions.