Santa Catarina

Controlled flight into terrain.
Contributing factors.
- Attitude - contributed
The fact that the pilot continued the descent visually, not performing the instrument approach according to the IFR flight plan, denoted disregard of the real risks of this action. Thus, his attitude contributed to the inappropriate approach that culminated in the collision with the ground.
- Adverse weather conditions - contributed
Despite the aerodrome presenting ceiling and visibility conditions favorable for visual flight at the time of the accident, it was verified that there was dense fog covering the entire region near the impact site and, therefore, the IFR rules, which determined a minimum altitude of 5,000 ft, should have been observed.
- Emotional state - undetermined
Some events in the pilot's personal life were negatively affecting his emotional state. In addition, the pilot appeared to be more introspective in the period leading up to the accident.
Thus, it is possible that his performance was impaired due to his emotional state.
- External influences - undetermined
The pilot was possibly experiencing difficult events in his personal life. These events could have negatively affected his emotional state.
Thus, the pilot's way of thinking, reacting and performance at work may have been impacted by factors external to work.
- Motivation - undetermined
The pilot intended to return home because he would be celebrating his birthday and that of his stepdaughter.
The audio recording of the pilot's telephony with the GND-FL, shows that he insisted to accelerate his take-off, denoting a possible high motivation focused on fulfilling his eagerness to accomplish the flight. This condition may have influenced the flight performance.
- Decision making process - contributed
The choice to continue the descent without considering the IFR rules, based on an inadequate judgment of the meteorological conditions, revealed the pilot's difficulties to perceive, analyze, choose alternatives and act adequately in that situation.

Contributing factors:
- Application of commands – undetermined
Considering the hypothesis of spatial disorientation, of the disabling type, it is possible that the pilot has reached a situation of complete inability to operate correctly controls the aircraft in order to regain control of the flight.
- Attitude – undetermined
It is possible that the high subordination of the pilot to the requests of his boss has made it difficult for you to position yourself in relation to your limitation in flying at night and in instrument flight meteorological conditions.
- Disorientation – undetermined
Conditions favorable to disorientation, that is, the night flight over the sea, within clouds and manual operation, as well as the dynamics of the aircraft trajectory recorded by the radar, among other factors, make spatial disorientation the main hypothesis for the accident.
- Visual illusions – undetermined
It is also possible that the pilot suffered visual illusions when flying over the sea in night time. When not seeing the lighting on land, and being at night dark, with cloudiness, the pilot may have confused spatial references.
- Instruction – undetermined
It is possible that the lack of familiarity with the English language has made it difficult, in to some degree, knowledge of the resources, equipment and systems present in the aircraft, as well as in the instruction received in a flight simulator.

The following findings were identified:
- There was the participation of psychological variables at individual level, related to the profile of the pilot, such as excessive self-confidence in assuming that he always reached his destination, the knowledge of the region and probably the self-induced pressures by the situation in the cabin, combined with the prevailing meteorological condition, as well as the fact that he made a mistake with the procedure he was performing, demonstrating the adoption of an inadequate decision, excessive motivation for landing and lack of attention to the correct procedure.
- It was not possible to perform an effective analysis on the parts and instruments of the aircraft, in view of their degree of destruction, thus the contribution of this factor to the accident could not be determined.
- Weather conditions at destination were fickle and deteriorated during the execution of the descent procedure of the aircraft, contributing to the accident.
- The pilot failed to comply with the planned descent profile in use.
- Despite being aware of the meteorological conditions at destination, the pilot did not adequately plan the accomplishment of the procedure of descent by instruments, coming to throw out of the established profile, suggesting that he did not undertake the briefing of descent.
- The performance of the procedure outside the foreseen profile and in instrument flight conditions, determine the participation of this aspect in the occurrence.

The crew continued the approach at an unsafe altitude for unknown reasons. At the time of the accident, weather conditions were poor, which was considered as a contributing factor as well as the lack of crew training.

It is believed that the crew failed to prepare the flight according to published procedures, did not follow the pre-departure checklist and failed to verify the position of the pressurization mode selector prior to take off. At an altitude of 33,000 feet, after suffering hypoxia, both pilot lost consciousness and situational awareness. Maybe one of them fell and the control column, causing the aircraft to enter an uncontrolled descent.

The following factors were identified:
- Weather conditions were marginal with atmospheric turbulences,
- Loss of control after the captain exercised poor judgment about weather conditions and demonstrated overconfidence as he was trying to beat his speed record on this leg,
- Lack of administrative, technical and operational crew surveillance by the operator,
- Poor crew coordination,
- Excessive speed on descent,
- The radiosonde from the meteorology surveillance center based in Curitiba was unserviceable.

The following findings were reported:
- Possible crew fatigue that diminished their performances,
- Possible psychological and organizational diminution,
- Possible inadequate supervision of the operator in flight planning, and non-compliance with procedures in force,
- Following a lack of crew resources management, the crew failed to follow the standard descent procedures,
- Poor approach planning on part of the crew,
- It is possible that the crew did not observe sufficient rest time,
- It is also possible that there was an intentional disobedience by the crew of ATC rules and operational standards, in relation to the use of the GPS equipment during the descent, even though this was not approved for such procedure.

The following factors were reported:
- The flight schedule to which the crew members were being subjected at the time they were operating in the company was contrary to Law 7.183 of 1984 and may have led them to chronic fatigue and stress conditions.
- There are indications that psychological variables at the organizational level, with respect to flight scale, training, standardization and procedures of the company and the flight group contributed to the accident.
- Throughout the operation, both crew members showed signs of anxiety, complacency, underestimation regarding the information received, motivation, change in perceptual synthesis, illusion and inattention.
- The cloud base and visibility conditions made it difficult to navigate and identify the control points on the ground, as well as making it impossible to see the obstacles.
- Insufficient planning has led to crew members failing to navigate and fly themselves.
- The failure of the crew to judge in relation to continued flight in adverse weather conditions and below the limits set by the Rules of the Air (IMA 100-12) contributed to the accident.
- There is evidence of the company's involvement in the investigation process, which did not give the crew the full technical conditions necessary for the flight to take place.
- The failures committed on this flight indicate that at least one crew member failed to use the available navigation resources and the other failed to advise.
- There was an influence of the visibility and ceiling conditions, as well as the physical environment, in relation to the similarity between the valleys of the Itajaí River and Itajaí Mirim. There is also evidence that conditions in the administrative-operational environment of the company and the group of pilots contributed to the difficulties the pilots faced.
- The errors found imply failures of supervision in the flight schedule sector, with regard to compliance with the law, training and operations sector.
- The crew had little experience as pilots in the company and on the route flown.