Rio de Janeiro

Contributing factors:
- Adverse meteorological conditions - a contributor
At the moment of the impact of the aircraft, there was rain with rainfall potential of 25mm/h, covering the Paraty Bay region, and the horizontal visibility was 1,500m. Such horizontal visibility was below the minimum required for VFR landing and take-off operations. Since the SDTK aerodrome allowed only operations under VFR flight rules, the weather conditions proved to be impeding the operation within the required minimum safety limits.
- Decision-making process - a contributor
The weather conditions present in SDTK resulted in visibility restrictions that were impeding flight under VFR rules. In this context, the accomplishment of two attempts to approach and land procedures denoted an inadequate evaluation of the minimum conditions required for the operation at the Aerodrome.
- Disorientation - undetermined
The conditions of low visibility, of low height curve on the water, added to the pilot stress and also to the conditions of the wreckage, which did not show any fault that could have compromised the performance and/or controllability of the aircraft, indicate that the pilot most likely had a spatial disorientation that caused the loss of control of the aircraft.
- Emotional state - undetermined
Through the analysis of voice, speech and language parameters, variations in the emotional state of the pilot were identified that showed evidence of stress in the final moments of the flight. The pilot's high level of anxiety may have influenced his decision to make another attempt of landing even under adverse weather conditions and may have contributed to his disorientation.
- Tasks characteristics - undetermined
The operations in Paraty, RJ, demanded that pilots adapt to the routine of the operators, which was characteristic of the executive aviation. In addition, among operators, possibly because of the lack of minimum operational requirements in SDTK, the pilots who landed even in adverse weather conditions were recognized and valued by the others. Although there were no indications of external pressure on the part of the operator, these characteristics present in the operation in Paraty, RJ, may have favored the pilot's self-imposed pressure, leading him to operate with reduced safety margins.
- Visual illusions - undetermined
The flight conditions faced by the pilot favored the occurrence of the vestibular illusion due to the excess of "G" and the visual illusion of homogeneous terrain. Such illusions probably had, consequently, the pilot's sense that the bank angle was decreasing and that he was at a height above the real. These sensations may have led the pilot to erroneously correct the conditions he was experiencing. Thus, the great bank angle and the downward movement, observed at the moment of the impact of the aircraft, are probably a consequence of the phenomena of illusions.
- Work-group culture - a contributor
Among the members of the pilot group that performed routine flights to the region of Paraty, RJ, there was a culture of recognition and appreciation of those operating under adverse conditions, to the detriment of the requirements established for the VFR operation. These shared values promoted the adherence to informal practices and interfered in the perception and the adequate analysis of the risks present in the operation in SDTK.

Contributing factors:
- Attention - undetermined
Moments before the accident, another aircraft successfully completed the landing at the Paraty aerodrome. It is possible that the pilot's attention was focused on this information, which indicated the possibility of landing, despite the critical conditions faced, leading him to take high risks to make the landing in critical conditions.
Also, the presence of a copilot not qualified to operate the aircraft may have influenced the pilot's cognitive processes, causing deconcentration or deviation of attention from the pilot.
- Attitude - contributed
Recurring attempts to make the landing indicated an excess of self-confidence on the part of the pilot, leading him to continue the flight to the Paraty aerodrome, even in adverse weather conditions.
The bold operational profile of the pilot, his past experience and the rules and values ​​adopted informally in the group of pilots are possible factors that influenced the development of this attitude of excessive self-confidence.
- Adverse weather conditions - contributed
On the day of the accident, the weather conditions were not favorable for visual flight at the Paraty aerodrome.
- Culture of the working group - contributed
Among the pilots who operated in the Paraty region, competitive behavior had been installed, valued by the social recognition attributed to those who managed to operate in critical conditions. Above all, landing under conditions adverse weather conditions in the region was considered a manifestation of proficiency and professional competence. The values ​​shared by that group of pilots favored the weakening of the collective perception about the present operational risks. The presence of other pilots who were also trying to land in the region on the day of the occurrence, as well as the landing made by one of these aircraft, moments before the accident, and also the accomplishment of two failed attempts of the PP-LMM aircraft, translates clear evidence of that behavior.
- Pilot forgetfulness - undetermined
The fact that the landing gear was not retracted during the second launch in the air indicated a failure, fueled by the possible forgetfulness of the crew, to perform the planned procedure. Maintaining the landing gear in the lowered position affected the aircraft's performance during the ascent, which may have contributed to the aircraft not reaching the height required to clear obstacles.
- Pilotage Judgment - undetermined
The possible decision not to retract the landing gear during the launch affected the aircraft's performance during the climb, which may have contributed to the aircraft not reaching the height necessary to clear the obstacles.
- Motivation - undetermined
The successful landing by the pilot of another aircraft, even under unfavorable conditions, may have increased the motivation of the pilot of the PP-LMM aircraft to complete the landing, in order to demonstrate his proficiency and professional competence.
- Perception - contributed
The occurrence of a collision with the ground, in controlled flight, indicated that the crew had a low level of situational awareness at the time of the occurrence. This inaccurate perception of the circumstances of the flight made it impossible to adopt the possible measures that could prevent the collision.
- Decision making process - contributed
The pilot chose to make two landing attempts at the Paraty aerodrome, despite adverse weather conditions, indicating an inaccurate assessment of the risks involved in the operation. This evaluation process may have been adversely affected by the competition behavior installed among the pilots. In this context, it is possible that the pilot based his decision only on the successful landing of another aircraft, a fact that limited his scope of evaluation.
- Organizational processes - undetermined
The PP-LMM aircraft was operated by a group of pilots, mostly composed of freelance professionals, who were informally managed by a hired pilot. Therefore, there was no formal system used by the operator to recruit, select, monitor and evaluate the performance of professionals. The failures related to the management of this process, possibly, caused inadequacies in the selection of pilots, in the crew scale, in untimely activations and, as in the case in question, in the choice of crew member not qualified to exercise function on board.

The collision with water and the subsequent accident was the consequence of the decision of the crew to continue the approach at low altitude to maintain a visual contact with the ground. At the time of the accident, the visibility was limited and weather conditions were marginal.

An error in the assembly was detected in the left generator, which interfered with the D+ terminal signal sent to the voltage regulator. Due to a voltage drop, some of the instruments lost their functionality. The following contributing factors were identified:
- The crew did not follow the emergency procedures;
- The crew decided to return to land at Santos Dumont Airport without considering that the runway length was less than the length required for an emergency landing;
- The speed of the aircraft while passing over the runway threshold was 25 knots above the reference speed;
- The pilots were unable to engage the spoilers or the thrust reversers;
- Wrong attitude from the captain;
- Overconfidence of the crew;
- Emotional load due to an emergency situation;
- Poor assessment of the situation due to high stress associated with decreased situational awareness;
- Poor crew coordination;
- Lack of crew resource management;
- Poor judgment;
- Lack of procedures on the part of the operator.

The following findings were identified:
- The crew considered the operation at Angra dos Reis Airport as unsafe, but operated the aircraft at that airport several times due to pressures from the aircraft's owner,
- The landing was completed with a tailwind component and a high aircraft weight, without considering the possibility to use runway 28, which demonstrated a poor assessment of the existing landing conditions,
- The relative short landing distance available, less than one km,
- The possible pressure exerted by the owner to carry out the flights, as well as the need to maintain the job or the professional image, may have contributed to the complacency behavior of the crew on the issues that lead to the operation of aircraft under conditions below acceptable safety standards,
- Poor flight planning,
- The relative low experience of the crew on this type of aircraft.

Controlled flight into terrain after the crew decided to continue under VFR mode in IMC conditions. The following contributing factors were identified:
- Overconfidence on part of the captain who was familiar with the area,
- The organizational culture of the company proved to be complacent by not inhibiting the adoption of procedures incompatible with flight safety, such as the low altitude flights made by the instructor captain,
- There was inadequate assessment of the situation by the crew, causing them to fly at a lower altitude than the safe limits under visual conditions unsuitable for visual flight, resulting in the collision of the aircraft with high ground,
- The use of human resources for the operation of the aircraft was unsuitable because of failure to comply with operational standards, leading the crew to perform a passenger flight to the lower altitude limits of safety, under inadequate visual conditions,
- The preparation for the flight proved inadequate because the crew did not have a meteorological analysis of the appropriate level of flight performed, considering that the conditions for the region were overshadowing the Serra do Mar and surrounding areas of low clouds and / or mist, especially on the slopes of the mountain,
- The weather conditions prevailing in the region made visual flight impossible, resulting in the concealment of the elevation at which the aircraft crashed,
- The pilots intentionally not complying with rules of air traffic and civil aviation rules, without grounds, performing flight at low altitude, under conditions of visibility below the limits established for VFR flight, colliding with high grounD,
- The company has not taken appropriate supervisory measures, enabling the existence of a culture of undeveloped flight safety, which prevented advance identification of actions taken by the crew and injured misconception exists in the CRM business, which represented a potential risk to their operations, as well as by the failure of some educational measures provided for in its PPAA (Plan for the Prevention of Aeronautical Accidents).

The accident was the consequence of a controlled flight into terrain after the crew decided to conduct this short flight under VFR mode in IMC conditions. The following contributing factors were identified:
- The visibility was reduced by the presence of a low ceiling over the mountains,
- Poor judgment on part of the crew regarding the existing flight conditions,
- Inadequate assessment of the distance between the aircraft and the ground,
- Continuation of the flight at an unsafe altitude for the area,
- Complacency and indiscipline of the crew,
- Poor flight planning,
- Lack of operational supervision.