São Paulo-Guarulhos

Contributing factors.
- Control skills - undetermined
Inadequate use of aircraft controls, particularly as regards the mode of operation of the Autothrottle in use and the non-reduction of the IDLE power levers at touch down, may have led to a conflict between pilots when performing the landing and the automation logic active during approach. In addition, the use of only one reverse (on the right engine) and placing the left throttle lever at maximum takeoff power resulted in an asymmetric thrust that contributed to the loss of control on the ground.
- Attitude - undetermined
The adoption of practices different from the aircraft manual denoted an attitude of noncompliance with the procedures provided, which contributed to put the equipment in an unexpected condition: non-automatic opening of ground spoilers and asymmetric thrust of the engines. These factors required additional pilot intervention (hand control), which may have made it difficult to manage the circumstances that followed the touch and led to the runway excursion.
- Crew Resource Management - a contributor
The involvement of the PM in commanding the aircraft during the events leading up to the runway excursion to the detriment of its primary responsibility, which would be to monitor systems and assist the PF in conducting the flight, characterized an inefficiency in harnessing the human resources available for the airplane operation. Thus, the improper management of the tasks assigned to each crewmember and the non-observance of the CRM principles delayed the identification of the root cause of the aircraft abnormal behavior.
- Organizational culture - a contributor
The reliance on the crew's technical capacity, based on their previous aviation experience, has fostered an informal organizational environment. This informality contributed to the adoption of practices that differed from the anticipated procedures regarding the management and operation of the aircraft. This not compliance with the procedures highlights a lack of safety culture, as lessons learnt from previous similar accidents (such as those in Irkutsk and Congonhas involving landing using only one reverse and pushing the thrust levers forward), have apparently not been taken into account at the airline level.
- Piloting judgment - undetermined
The habit of not reducing the throttle lever to the IDLE position when passing at 20ft diverged from the procedures contained in the aircraft-operating manual and prevented the automatic opening of ground spoilers. It is possible that the consequences of this adaptation of the procedure related to the operation of the airplane were not adequately evaluated, which made it difficult to understand and manage the condition experienced.
- Perception - a contributor
Failure to perceive the position of the left lever denoted a lowering of the crew's situational awareness, as it apparently only realized the real cause of the aircraft yaw when the runway excursion was already underway.
- Decision-making process - a contributor
An inaccurate assessment of the causes that would justify the behavior of the aircraft during the landing resulted in a delay in the application of the necessary power reduction procedure, that is, repositioning the left engine power lever.

The following findings were identified:
- The lack of a prompt identification of the aircraft stall by the captain may have deprived him of handling the controls in accordance with the prescriptions of the aircraft emergency procedures, contributing to the aircraft entry in an abnormal attitude.
- The captain’s attention was focused on the passengers sitting in the rear seats, in detriment of the flight conditions under which the aircraft was flying. This had a direct influence on the maintenance of a poor situational awareness, which may have made it difficult for the captain to immediately identify that the aircraft was stalling.
- There was complacency when the copilot functions were assumed by a person lacking due professional formation and qualification for such. Even under an adverse condition, the prescribed procedure was not performed, namely, the use of the aircraft checklist.
- The fact that the aircraft was flying under icing conditions was confirmed by a statement of the female passenger in the cockpit (CVR). The FL210 (selected and maintained by the captain) gave rise to conditions favorable to severe icing on the aircraft structure. If the prevailing weather conditions are correlated with reduction of speed (attested by the radar rerun), the connection between loss of control in flight and degraded aircraft performance is duly established.
- The rotation of the aircraft after stalling may have contributed to the loss of references of the captain’s balance organs (vestibular system), making it impossible for him to associate the side of the turn made by the aircraft with the necessary corrective actions.
- The non-adherence to the aircraft checklists on the part of the captain, in addition to the deliberate adoption of non-prescribed procedures (disarmament of the starter and “seven killers”) raised doubts on the quality of the instruction delivered by the captain.
- The captain made an inappropriate flight level selection for his flight destined for São Paulo. Even after a higher flight level was offered to him, he decided to maintain FL 210. Also, after being informed about icing on the aircraft, he did not activate the Ice Protection System, as is expressly determined by the flight manual.
- The captain had the habit of making use of a checklist not prescribed for the aircraft, and this may have influenced his actions in response to the situation he was experiencing in flight.
- His recently earned technical qualification in the aircraft type; his inattention and distraction in flight; his attitude of non-compliance with operations and procedures prescribed in manuals; all of this contributed to the captain’s poor situational awareness.
- The flight plan was submitted via telephone. Therefore, it was not possible to determine the captain’s level of awareness of the real conditions along the route, since he did not report to the AIS office in SBMG. In any event, the selection of a freezing level for the flight, considering that the front was moving along the same proposed route, was indication of inappropriate planning.
- The investigation could neither determine the whole experience of the aircraft captain, nor whether his IFR flight experience was sufficient for conducting the proposed flight, since he made decisions which went against the best practices, such as, for example, selecting a flight level with known icing.
- With a compromised situational awareness, the pilot failed to correctly interpret the information available in the aircraft, as well as the information provided by the female passenger sitting in the cockpit, and he chose to maintain the flight level under inadequate weather conditions.
- The lack of monitoring/supervision of the activities performed by the captain allowed that behaviors and attitudes contrary to flight safety could be adopted in flight, as can be observed in this occurrence.
- Apparently, there was lack of an effective managerial supervision on the part of the aircraft operator, with regard to both the actions performed by the captain and the correction of the aircraft problems.

The following factors were identified:
- During the approach, the flight crew's attention was focused on the characteristics of the geographical relief and presence of birds, reducing their awareness as to the maintenance of the approach slope.
- The group culture of maintaining a low angle of approach led the crew to choose the runway aspect instead of the VASIS as a reference for the approach, making them susceptible to various types of spatial illusion.
- Taking into account copilot's report that he was not succeeding in correcting the aircraft glide path relative to the runway, one may suppose that he was not applying the appropriate amplitude for such correction.
- The physical characteristics of the runway 15 (the active one) contributed to a wrong perception of the ideal glide path. The pronounced acclivity of the runway, its width (narrower than the runways on which the crew was accustomed to operate), and the low terrain near the threshold, caused in the pilots a perception that they were above the ideal approach slope, leading them to seek correction, which resulted in an angle of approach below the ideal one.
- For the flight in question, the company chose two pilots who had never operated in SBQV. A crewmember with previous experience in the locality would have a higher level of awareness in relation to the specific characteristics of the aerodrome.
- No company publications were found that could provide the pilots with guidance on the specifics of SBQV, capable of helping with the management of the risks associated with the operation in that aerodrome.

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 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.

The following findings were identified:
- The pilots' perception about the situation was affected by lack of specific training and procedures, which, coupled with the limited time available for action and lack of clarity in communications, influenced the time elapsed for taking corrective actions.
- Communication between the crew was not clear at the time of emergency, making the co-pilot did not understand at first, the action to be performed, which increased the time spent to disarm the CB. Such facts, however, can not be separated from the situation experienced by pilots with inadequate training for emergency and in a short time to identify the problem and take the corrective actions.
- The company had not provided a regular CRM training to pilots. Furthermore, the captain did not receive simulator training for over one year. It was impossible to determine, however, if the regular training and updating of the CRM simulator training of the pilot would have prevented the accident.
- The removal of the pilot from his seat at the time of the emergency may have increased the time spent in identifying the crash and taking corrective actions, but it was not possible to establish whether the accident would be avoided if he would have been in the cockpit. The copilot was slow to understand the situation and initiate corrective actions, although the alarm 'whooler' has sounded, also increasing the elapsed time.
- The operational testing under J IC 27-32-00 allowed the partial completion of the procedures due to lack of clarity, which allowed the release of the aircraft for flight with a defective relay.
Furthermore, although the elevator trim system has been certified, no procedure for emergency triggering of the compensator in the manuals provided by the manufacturer, no replacement intervals of the components of the elevator trim system in "Time Limits" systems normal and reserves were not independent and the system had a low tolerance for errors.

A loss of hydraulic fluids occurred on a hose separating a fitting from a pump on the right engine, causing the malfunction of the primary hydraulic system and resulting in the degradation of the mechanical system of the landing gear control command.

While cruising at FL350, the crew noticed a technical problem with the 'fuel filter' and a 'fuel pressure low' was observed on the right engine. Following a check of the flight manual, the crew reported a fuel transfer issue and attempted an emergency diversion. It was determined that both engine stopped following the rupture of a fuel line connected to the right engine, causing a major fuel leak. The disconnection of the fuel line was the consequence of the rupture of a aluminium ring.