Minas Gerais

Loss of control after the crew initiated aerobatic maneuvers at low altitude.

The following factors were identified:
- The pilot may have displayed a complacent attitude, both in relation to the operation of the aircraft in general and to the need to accommodate his employers’ demands for arriving in SBJF. It is also possible to infer a posture of excessive self-confidence and confidence in the aircraft, in spite of the elements which signaled the risks inherent to the situation.
- It is possible that the different levels of experience of the two pilots, as well as the copilot’s personal features (besides being timid, he showed an excessive respect for the captain), may have resulted in a failure of communication between the crewmembers.
- It is possible that the captain’s leadership style and the copilot’s personal features resulted in lack of assertive attitudes on the part of the crew, hindering the exchange of adequate information, generating a faulty perception in relation to all the important elements of the environment, even with the aircraft alerts functioning in a perfect manner.
- The meteorological conditions in SBJF were below the minima for IFR operations on account of mist, with a ceiling at 100ft.
- The crew did not inform Juiz de Fora Radio about their passage of the MDA and, even without visual contact with the runway, deliberately continued in their descent, not complying with the prescriptions of the items 10.4 and 15.4 of the ICA 100-12 (Rules of the Air and Air Traffic Services).
- The crew judged that it would be possible to continue descending after the MDA, even without having the runway in sight.

There was sufficient fuel in the tanks at the time of the accident as the aircraft was refueled prior to departure for a 5-hour flight. The exact cause of the double engine failure remains unknown. When the right engine failed, the pilot was flying at an altitude of 330 feet which was below the minimum safe altitude fixed at 500 feet. Also, he was apparently using his cell phone.

Late use of the normal brake systems on part of the crew after landing, causing the aircraft to overran. The captain had the habit of braking the aircraft while using the reverse thrust systems only in order to save the braking systems. Doing so, the use of the normal brakes was delayed.

The decision of the crew to descend below MDA in below weather minimums. The following contributing factors were identified:
- Low visibility (night),
- Poor judgment on part of the crew,
- Poor approach planning,
- Lack of supervision,
- The pilot acted on the controls of the aircraft to allow it to stall during the approach, losing its control and colliding with the obstacles,
- Poor crew coordination,
- Lack of discipline.

The right engine suffered a oil leak in flight following the failure of a hose due to poor maintenance. The following contributing factors were identified:
- Both pilots did not have sufficient experience nor training on this type of aircraft,
- The copilot was flying for this operator for the first time,
- The operator was unable to provide any maintenance documentation nor crew training documentation to investigators,
- Both engines were running at impact but with limited power,
- The right propeller was feathered at impact.

Loss of power on the right engine for undetermined reasons. The following findings were identified:
- Poor flight preparation on part of the crew,
- The crew did not know the exact weight of the mail/cargo,
- The crew did not have sufficient training/instruction regarding a possible loss of engine power at takeoff,
- Poor engine maintenance as the right engine had experienced power issues in the past that had not been resolved,
- Poor crew coordination,
- When the loss of power occurred on the right engine, the captain asked the copilot to raise the landing gear and preferred to resolve the emergency situation alone,
- Poor evaluation of the aircraft performances on part of the crew in regard of the weight and balance values and CofG.

It is believed that the pilot lost control of the aircraft in poor weather conditions after he suffered a spatial disorientation. The following contributing factors were identified:
- Poor flight preparation,
- Poor weather conditions with atmospheric turbulences,
- The pilot showed anxiety and complacency,
- The pilot was not properly licensed to operate in IFR conditions,
- The pilot was inexperienced,
- The pilot's actions were likely inappropriate while facing an unexpected situation.

Failure of the left engine that was not lubricated according to published procedures. Inappropriate engine maintenance on part of the operator. Also, it was reported that the pilot's experience on this type of aircraft was insufficient.