Amazonas

The right main gear collapsed during takeoff following a structural failure caused by the presence of fatigue cracks that were not detected by the maintenance crew because of poor maintenance. The aircraft already suffered an accident in Guarulhos Airport, causing damages to the right main gear.

Controlled flight into terrain after the crew continued the descent below 2,000 feet until the aircraft impacted ground. The following contributing factors were identified:
- The crew reported his altitude at 2,000 feet while the real altitude of the airplane was 1,300 feet,
- The crew continued the descent until final impact,
- The crew did not react to the GPWS alarm that sounded four times when the aircraft reached the altitude of 400 feet,
- No corrective action was taken by the crew,
- Lack of crew coordination,
- Poor approach planning that led the aircraft descending to a critical altitude,
- Lack of supervision,
- Operational deficiencies.

The following factors were identified:
- The crew did not have sufficient training to enable the desired assertiveness for the correct use of aircraft resources, which would probably have prevented the accident, since, instead of applying the emergency brake, they applied reverse with the feathered props, contrary to the procedure provided for in the Aircraft Manual.
- The maintenance services were not efficient, as they did not comply with the Aircraft Maintenance Manual in relation to the dimensional adjustment of the Hub Cap Drive Clips' drive clips, and the Service Bulletin incorporated stickers to the outer doors of the main landing gear, as a reminder to the mechanic to check the clearances.
- The copilot failed to apply the reverse pitch on the propellers as they were feathered, and at that moment the emergency brake should be commanded to brake the aircraft.
- The company failed to adequately check the execution of the actions provided for in the Aircraft Maintenance Manual regarding the 'Antiskid' system and to verify the application of all service bulletins issued by the manufacturer.

The aircraft suffered aquaplaning after landing and was unable to stop within the remaining distance. The following contributing factors were identified:
- The operator authorized the crew to divert to an unapproved airport with an aircraft weighing more than the limits specified in the operations manual without performing adequate supervision in the execution of the flight;
- Deviations on part of the crew;
- Lack of Crew Resources Management;
- Lack of crew coordination and communication;
- Lack of crew instruction and training on part of the operator;
- Poor weather conditions with heavy rain falls;
- The runway surface was wet and the aircraft suffered aquaplaning;
- The aircraft was overloaded;
- The landing was completed with a tailwind component;
- The crew failed to perform the approach briefing according to published procedures.

The following factors were identified:
- It was not possible to examine the debris of the aircraft to determine the contribution of this factor to the failure of the left engine.
- It is possible that the failure to carry out a type B2 inspection and/or to carry out a type A1 inspection by an unqualified person may have contributed to the occurrence of a low oil pressure emergency, due to material deterioration or inadequate services. The impossibility of examining the aircraft could not determine this aspect.
- The owner of the air taxi company participated due to lack of adequate supervision in the planning of operations, at the technical, operational and administrative levels. This deficiency can be characterized, among other things, by the owner of the company that allowed the aircraft to fly with the type B2 inspection expired; by the excessive amount of fuel, when refueling in Manaus; by the unreasonable number of people on board, causing the aircraft to fly with excess weight, and still, by the receipt of pilots' salary to be conditioned to the accomplishment of the fateful flight.
- Errors were made by the aircraft crew due to the improper use of the resources available in the cabin, intended for the operation of the aircraft, due to non-compliance with operational rules.
- There was a mistake made by the crew due to the inadequate preparation for the flight, assuming numerous failures, such as: the non conference, by the pilots, of the cargo and passengers manifest; the lack of the realization of a briefing and still, to accept an aircraft for a flight, being the same with its inspection not carried out.
- An error was made by the crew due to inadequate evaluation of certain aspects of the flight. Such deficiency was evidenced when the first sign of failure of the lubrication system occurred, after twenty minutes of flight, and even so, they decided to proceed with the flight, when the most sensible and safe would be the return, immediately, to Manaus.
- The airline's support staff participated in the planning of weight and balance of the aircraft and the number of passengers on board, providing incorrect information to the aircraft's crew members. In addition, the mechanic who performed the A1 type inspection was not qualified for the function.
- There has been intentional non-compliance by the crew members with the operational rules established by the aircraft manufacturer.
- The Commander did not foresee what was predictable, for lack of caution, thus intentionally increasing the risk margin of the mission.

Contributing factors
a. Human Factor
(1). Psychological Aspect
It contributed, since the pilot in command adopted an improvisational attitude through the adoption of unforeseen procedures in the face of the insistence on landing, despite the weather conditions present. A likely channeling of attention to external references may have contributed to the loss of operational performance, leading to the loss of the maintenance condition of the basic flight parameters.
(2). Physiological Aspect
Undetermined since the absence of interference from toxicological factors was not effectively verified.
b. Material Factor
Didn't contribute.
c. Operational Factor
(1). Deficient Instruction
It contributed since there was no periodic simulator training and also no cockpit resource management (CRM) training.
(2). Deficient Supervision
It contributed since there was no adequate monitoring of the circumstances of operation by the Company's operations sector and, also, there were no defined and clear rules and specific operating routines that adequately addressed the various aspects of the operation.
(3). Little Flight or Aircraft Experience
It contributed because of the small experience in the aircraft by the copilot.
(4). Influence of the Environment
It contributed since visibility was limited at the time of the accident.
(5). Deficient Cockpit Coordination
Contributed since there was no briefing to the accomplishment of the descent procedure by instruments, the copilot did not follow the execution of the procedures after the critical point since he concentrated his attention to the search of external references, thus abandoning the monitoring of the flight parameters.
(6). Disabled Infrastructure
Indetermined since the influence of the low accuracy of the NDB on the heading lags occurred in the descent procedure was not perfectly established and no effective test was performed.
(7). Poor Planning
It contributed because there was no briefing in the procedure of descent by instrument and approach lost.
(8). Deficient discipline of Flight
The pilot therefore continued the flight, without visibility, at an altitude below the minimum for this operating condition.
(9). Adverse Weather Conditions
It contributed as the prevailing weather conditions were marginal, with the aerodrome closed for IFR operation.

It was reported that the crew adopted a wrong takeoff configuration and that the rate of climb and gradient were too low after takeoff (positive but insufficient vario), causing the aircraft to collide with an equipment of the approach light system.

Engine problems for unknown reasons.