Brazil

The accident occurred in poor weather conditions. It was determined that during initial climb, the aircraft's attitude, speed and altitude varied suddenly and rapidly, causing the pilot flying a stressful situation insofar as he believed that artificial horizons presented technical problems. In such a situation, investigators consider probable the hypothesis that the pilot made inadequate corrections, exacerbating the abnormal situation in which he was operating. The following contributing factors were identified:
- The crew were suffered fatigue because they had been on duty for more than 15 hours and were unable to observe satisfactory rest time at Congonhas airport,
- This fatigue certainly affected the pilots in their decision-making,
- The urge to return home and distrust of instruments in difficult flight conditions seriously compromised the performance of pilots and their ability to make decisions,
- A direct contact with passengers was stressful as they were going through a period of mourning and were eager to return home to Maringá,
- Weather conditions were unfavorable and contributed to the anxiety of the crew,
- Poor assessment of these conditions by the pilots,
- The working time of the pilots exceeded the limitations and the operator did not take into account adequate rest conditions for the crew,
- The training of the captain in instrument flights in recent months was insufficient.

Both engines failed 12 minutes apart due to fuel exhaustion. The following contributing factors were identified:
- Fuel tanks were empty,
- The fuel quantity was insufficient to cover the requested flying distance,
- Poor flight preparation and planning,
- Complacency on part of the copilot,
- Wrong decisions on part of the captain,
- Failures in the organization of flights within the operations of the Government of the State of Goiás,
- Miscalculations in fuel consumption.
- Operating an airplane with faulty fuel gauges,
- Failures in monitoring related to flight safety culture,
- Poor crew resources management,
- Poor crew coordination,
- Lack of crew interactions.

Failure of the left engine that was not lubricated according to published procedures. Inappropriate engine maintenance on part of the operator. Also, it was reported that the pilot's experience on this type of aircraft was insufficient.

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.

Engine failure due to poor maintenance. The following contributing factors were identified:
- Maintenance procedures not followed by the operator mechanics,
- Poor crew coordination,
- Lack of crew training.

Double engine failure on final approach due to fuel exhaustion. The following contributing factors were identified:
- Poor flight preparation and planning,
- The crew was overconfident,
- The crew miscalculated the total fuel quantity needed for the entire mission,
- Wrong fuel consumption calculation,
- Taxing time and wind component were not taken into consideration in the fuel consumption calculation,
- Incorrect values relative to the aircraft performances,
- Poor crew resources management.

The following findings were identified:
- The total weight of the aircraft upon departure from Belém Airport was 650 kilos above MTOW,
- The cargo was not stowed in the cabin but simply stored on the floor,
- The left engine was not providing power at impact and the aircraft entered a left turn and then an uncontrolled descent until impact with the ground,
- Failure of the left engine due to the presence of an aluminum part obstructing the fuel pipe. Metallographic analyzes confirmed that this aluminum part likely came from a thread of the fuel pump,
- Complacency of the crew who failed to follow the published procedures of the operator.

Failure of both engines in flight due to fuel exhaustion. The following findings were identified:
- The crew failed to prepare the flight according to published procedures,
- The crew failed to check there was sufficient fuel in tanks prior to departure,
- The crew failed to follow the pre takeoff checklist,
- The captain showed excessive self confidence
- The captain exercised pressure on the copilot,
- The crew suffered fatigue due to an excessive period of work. At the time of the accident, the crew was overduty by three hours,
- The crew consumed alcohol beverages the night before the flight.

Contributing Factors:
- There was the participation of individual psychological variables in the pilot-in-command's performance due to the excess of self-confidence and self-demand in his customary behavior, besides the dissimulation regarding his real qualification for the type of flight. The personality with traces of permissiveness and insecurity of the co-pilot also contributed to the occurrence, as it allowed the aircraft to be operated by an unqualified pilot, with no employment link with the company.
- There was a lack of adequate supervision by Manacá Táxi Aéreo, as it allowed a crew member who had not operated the type of aircraft for one year and had not made any type of flight for four months, besides not having any employment relationship with that company. It is also necessary to consider the failure of supervision at the organizational level due to the issue of an incorrect license by the DAC, giving rise to the possibility of its use for the revalidation of license in aircraft for which the pilot was not qualified to exercise the function of commander.
- The entire sequence of events began with pilot errors resulting from the pilot's lack of flight experience in the left-hand seat on the aircraft in question.
- The inadequate use of cockpit resources destined to the aircraft operation, due to an ineffective accomplishment of the tasks assigned to each crew member, besides the interpersonal conflict resulting from the co-pilot's intervention in the pilot in command operation, in the final approach phase, already close to the aircraft's touchdown, configure the collaboration of this factor to the accident.
- The inadequate use of the aircraft commands, by the pilot in command, making excessive aileron corrections in the final approach phase, near the landing.
- The pilot was qualified as a co-pilot on the equipment, but due to a typing error, he was issued a pilot license. Thus, the situation and operation of the pilot in question were totally irregular.

The following findings were identified:
- The crew was in a hurry to take off in order to avoid poor weather approaching the airport,
- The crew took off from an intersection with a taxiway,
- Immediately after takeoff, the aircraft entered clouds,
- Approximately one minute after liftoff, the aircraft impacted ground,
- After the first impact, the aircraft flew for another 200 metres and again collided with the ground and exploded,
- The aircraft was totally destroyed by a post crash fire,
- The pilot had a hearing problem that was stabilized and was being researched by HASP. Considering the relationship between ear and ear balance, spatial disorientation in the pilot in
in the face of the adverse conditions it experienced: flight conditions by instruments associated with “windshear”. Since the search could not be completed above mentioned, this aspect remains undetermined,
- Individual characteristics contributed due to the habits acquired by the pilot and his eventual practice of taking off from the taxiway, delaying the point from which the aircraft would achieve the best characteristics flight performance,
- Poor weather conditions with CB's, sudden changes in wind, strong turbulence and rain, were conducive to the emergence of the phenomenon of “Windshear”, representing a real risk to the operation of any aircraft, being that voluntary entry or not, in this type of training, results almost always in the loss of control of the aircraft with unforeseeable consequences. The crew faced these conditions when the aircraft took off,
- It was evident from the witness statements that the pilot was in a hurry to take off, in addition to having used runway 23 from the intersection and towards the sector most affected by poor weather.