Transportes Aéreos Meridionais

It was determined that the engine failure was probably caused by the failure of a blade on the high-pressure compressor, possibly as a result of a manufacturing defect. The following contributing factors were identified:
- The crew failed to feather the propeller after the engine failure,
- The flaps were lowered at an angle that caused a speed reduction,
- Lack of crew coordination,
- The crew failed to follow strictly the checklist and missed certain points,
- The fact that the crew was flying under IFR mode at the time the engine failed aggravated the situation, making it difficult to carry out the planned procedures and ruling out an early choice of an emergency landing site,
- The poor visibility due to the night impeded a proper choice and planning of the emergency landing 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.

The following contributing factors were reported:
- The traffic and the high number of landings caused a natural fatigue by the instructor and reduced his appreciations,
- There were too much pilots under training for one single instructor,
- The copilot's experience was insufficient with only one hour on Cessna 208,
- Poor crew coordination,
- Poor crew action on engine power to expect recovery after stall.

The following findings were reported:
- There was a deficiency in the instruction received, since the crew did not perform emergency training on that type of aircraft, resulting in inadequate preparation for the engine failure situation, especially at low altitude,
- There are indications that the maintenance services were inadequate and contributed to the occurrence of engine failure, due to the possible occurrence of compressor stall,
- The company performed inadequate technical and operational oversight for not providing emergency situations for the crews of that type of aircraft involved in the accident.