Brazil

Contributing factors:
- Attitude – a contributor.
Familiarity with the destination aerodrome, developed through recent experience, along with experience in this type of operation, generated a complacent attitude toward safety procedures and excessive confidence in the pilots’ ability to handle the situation.
These attitudes led to inadequate adherence to the procedures required in the presence of an engine malfunction. Additionally, the decision to continue the flight and landing under VFR, despite adverse meteorological conditions, reflected difficulty in reacting appropriately to external stimuli affecting the operation, resulting in inadequate behaviors and compromising flight safety.
- Training and Qualification – undetermined.
There were no records indicating that the pilots had completed CRM training, as required by Section 135.330 of RBAC 135. Furthermore, it is possible that the lack of completion of periodic flight training before the accident contributed to inadequate
performance and insufficient proficiency in the context of the emergency operation and management.
- Communication – a contributor.
During the management of the emergency, the crew demonstrated difficulty organizing and expressing information rationally and coherently. The PIC’s unclear and low assertiveness verbalizations hindered the SIC’s ability to properly interpret and act upon the
instructions. This situation worsened during the go-around after the first landing attempt, when the PIC repeatedly issued commands using non-standard phraseology, delaying actions on the part of the SIC. Throughout the second traffic circuit, information exchange between the pilots was insufficient to establish an orderly definition of the commands and actions to be executed before shutting down the left engine on final approach.
- Adverse meteorological conditions – undetermined.
Meteorological conditions below the minima for VFR and for landing at SIXE may have affected aircraft performance and induced the pilots to conduct engine-malfunction procedures at low altitude to maintain ground reference, reducing the safety margin during the ensuing loss of control.
- Crew Resource Management – a contributor.
Human resources available for the operation were inefficiently employed, with inadequate management of each crew member’s actions and a failure to consult emergency checklists.The confusion observed on the CVR indicated that, once assuming control of the
aircraft, the PIC struggled to provide clear direction to the SIC during critical flight phases, particularly during the landing attempt and the subsequent left-engine shutdown on final. At no point did the crew engage in dialogue aimed at analyzing the situation,
interpreting available information, or consulting checklists to support decision-making.
- Handling of aircraft flight controls – undetermined.
CVR transcripts showed that, when control was lost, the PIC applied maximum power on the right engine. Under those circumstances, the action performed by the crew may have aggravated the aircraft’s loss-of-control condition, which resulted in a left descending turn that continued until ground impact.
- Piloting judgment – a contributor.
There was inadequate assessment of aircraft operational parameters prior to shutting down the left engine. This misjudgment led the crew to perform the shutdown on final approach, at low altitude and with the aircraft fully configured for landing – conditions under which sustained flight was no longer possible. Additionally, shutting down the engine during final approach prevented recovery of control in the new single-engine flight condition due to insufficient altitude.
- Aircraft maintenance – undetermined.
The possibility of maintenance personnel involvement could not be ruled out, due to inadequacies in the corrective or preventive actions taken regarding discrepancies recorded in the Aircraft Logbook by the same crew days prior to the accident. At that time, a mismatch between the power-lever positions had been noted. It was considered that this condition may have been associated with the onset of FCU malfunction, through an incipient fracture in the bellows.
- Decision-making process – a contributor.
Evidence collected during the investigation suggests difficulty in perceiving, analyzing, and appropriately responding to the situation, resulting in hasty decision-making and inadequate use of available time to implement a safe course of action. During arrival at SIXE, inadequate evaluations and/or indecision were identified regarding measures to mitigate the emergency in question. By choosing to land at SIXE, the pilots did not comply with the meteorological minima prescribed for that operation, reducing the safety margin when shutting down the malfunctioning engine – an action that led to loss of control. Misinterpretation and insufficient analysis led to an underestimation of the seriousness of the situation, resulting in the decision to shut down the engine during final approach at an aerodrome lacking emergency response capability, without notifying air traffic services of the aircraft’s emergency condition.
- Managerial oversight – undetermined.
One deemed plausible that there was inadequate oversight by the organization’s management regarding pilot training activities and monitoring of qualifications. Additionally, in response to reports of discrepancies, the aircraft maintenance manager may not have adequately addressed abnormal behaviors exhibited by the aircraft – such as the power-lever mismatch – prior to the accident.

Contributing factors:
- Training – undetermined.
The frequent and improper use of the EPL (Emergency Power Lever) during emergency landing training throughout the aircraft’s operation may have contributed to engine degradation.
- Work-group culture – undetermined.
The recurring improper use of the EPL by multiple pilots during the operation of the aircraft may have contributed to engine degradation.
- Handling of aircraft flight controls – undetermined.
It is possible that the pilot's use of the aircraft’s EPL was inappropriate and contributed to the severity of the accident.
- Aircraft maintenance – a contributor.
Given the large number of seat belts that detached as a result of the shearing of their floor attachment brackets and their corroded condition, it was determined that the maintenance actions were not effective in ensuring the integrity and reliability of these materials, which contributed to the injuries sustained by the parachutists during the emergency landing.
- Managerial oversight – a contributor.
The oversight of the operational procedures related to the use of the EPL was not effective in identifying the risks associated with its use in disagreement with the aircraft manufacturer’s specifications.

Contributing factors:
- Adverse meteorological conditions – a contributor.
The significant weather, indicated with the proximity qualifier “vicinity” in the METAR for SBBR, encompassed the SSGP region and affected the aircraft’s stability on short final, requiring the pilot to perform additional control inputs compared to normal operating
conditions.
- Handling of aircraft flight controls – a contributor.
The improper use of flight controls during heading correction on final approach - due to wind gusts - and the failure to effectively neutralize the aircraft’s rolling tendency during the go-around maneuver contributed to destabilization on final and to the unsuccessful go around.
- Piloting judgment – a contributor.
The application of rudder to correct for lateral wind deviation, based on the belief that using aileron would result in loss of lift, reflected an inadequate assessment.
- Perception – undetermined.
It is possible that situational awareness was reduced due to the wind gust occurring near touchdown, where increased workload may have led to delayed or selective perception of the required action, in this case, the go-around procedure.
- Decision-making process – a contributor.
The decision to continue the approach, followed by exposure to another wind gust during a critical phase (low altitude and left of runway centerline), resulted in a delayed execution of the go-around procedure, highlighting difficulty in perceiving, analyzing, and
selecting appropriate alternatives for the situation encountered.

The following factors were identified:
- Attention – undetermined.
It was found the possibility that the PT-ONJ aircraft crew had their attention (focused vision) on the runway at the expense of maintaining proper separation with the terrain on a visual approach.
- Piloting judgment – a contributor.
Regarding the approach to landing profile, there was an inadequate assessment of the aircraft's operating parameters, since the downwind leg was elongated by a significantly greater distance than that expected for a "Category B" aircraft in landing procedures under VFR.
- Memory – undetermined.
It is likely that, based on the experience of ten years of operation in a company governed by the RBAC 121, the PIC procedural memory has influenced the decisions made concerning the conduct of the aircraft. The habit of performing long final approaches in another type of operation may have activated his procedural memory, involving cognitive activities and motor skills, making the actions automated in relation to the profile performed in the accident.
- Flight planning – undetermined.
A possible non-use of the available aeronautical charts (CAP 9453 and WAC 3189), which were intended to meet the needs of visual flight, may have contributed to low situational awareness about the characteristics of the relief around the SNCT Aerodrome and the presence of the power grid that interfered with the aircraft's landing approach.

Contributing factors:
- Attention - a contributor.
The analysis of the pilots' performance during the flight of the previous day revealed episodes of inattention, such as those related to the lowering of the landing gear. In the accident flight, the crew fixated on the excessive RPM, failing to notice in a timely manner that the speed was decreasing, something that limited their ability to promptly respond to the stall condition.
- Attitude - a contributor.
During the accident flight, it was noted that the aircraft rotated at a speed of 102 knots, being such speed consistent with the prescribed aircraft’s maximum takeoff weight. However, because the aircraft’s weight was 1,374 pounds above the MTOW, when it rotated at the referred speed, a continuous 1 kHz alarm sounded, indicating that it had entered a pre-stall condition. Such improvisational approach regarding the MTOW exacerbated the situation, contributing to the outcome of the accident.
Training - undetermined.
The classification of the aircraft by the Brazilian Regulatory Agency as a “class aircraft” may have contributed to the training required from pilots being insufficient to ensure their proficiency in handling emergencies on the B200GT aircraft.
- Work-group culture - undetermined.
According to reports, the belief that the King Air aircraft was capable of taking off with a weight greater than the one specified by the manufacturer was common among operators to whom the investigators had access. This belief may have contributed to the decision made to conduct the flight under those conditions, influencing the takeoff performance.
- Handling of aircraft flight controls - undetermined.
After the retraction of the landing gear, a command to reduce aircraft power was applied by the PIC, which preceded the stall warning. Following this warning, a possible command for feathering one of the propellers may have triggered loss of control of the aircraft.
- Piloting judgment - a contributor.
The takeoff in which the accident occurred was performed 1,374 pounds above the weight limit prescribed in the AFM. Speeds and parameters of a typical takeoff were used, with power being reduced shortly after the landing gear retraction. In this context, there was no adequate assessment of the flight parameters, culminating in the aircraft’s stall condition.
- Aircraft maintenance - undetermined.
Although one engine N2 maximum of 25 RPM greater than the Takeoff and Max Continuous value of 2,000 RPM verified at takeoff cannot be directly linked to the adjustments made to the propellers during the last inspection, the early release of the aircraft may have prevented a sufficiently thorough check of the maintenance tasks performed. This was found to have occurred the day before the accident after the first attempt to start up the engines. There were erasures on the record sheet that documented the engine parameters at entry and exit, leading to discrepancies in relation to the records made in the corresponding Service Order.
- Memory - undetermined.
The analysis of the Cockpit Voice Recorder’s audio spectrum revealed that the propellers were adjusted after the “propeller overspeed” callout was made by the PIC. Although this procedure was not prescribed for the B200GT, it was found to be practiced in the E110 aircraft, in which the PIC had developed much of his professional experience. It is possible that this action originated from the retrieval of previous conditioning, characterizing what is known as “negative transfer”.
- Perception - a contributor.
The stall condition, likely related to the gradual reduction in speed that followed the reduction of the power levers, was not perceived in a timely manner for a reaction to be planned. In that context, there was exclusively a perception of the slightly excessive propeller RPM, a maximum amount of 25 RPM, which impaired the situational awareness regarding the other aspects of the flight.

Contributing factors:
- Attention – undetermined.
It is possible that the aircraft’s encounter with a kite led to a delayed and imprecise response to operational cues, which may have resulted in a breakdown in the alert and distraction management system, specifically regarding landing gear extension.
- Attitude – undetermined.
Conducting the flight with an unqualified pilot reflected the adoption of inappropriate attitudes such as complacency, overconfidence, and disregard for the requirements established in RBACs 91 and 61, which may have contributed to this accident.
- Crew Resource Management – a contributor.
Inefficient use of the human resources available for the aircraft operation led to inadequate task management among the crew. The PIC never questioned the aircraft’s readiness for landing, and the pilot occupying the right seat failed to monitor the aircraft configuration or assertively advise on the landing gear position for touchdown.
- Perception – a contributor.
During the approach, the aural warning indicating that the landing gear was still retracted was activated and could be heard on the CVR audio. However, the pilots took no corrective action, evidencing impaired ability to recognize and interpret internal environmental cues, which led to reduced situational awareness and culminated in a gear up landing.
- Limited pilot’s experience – undetermined.
Considering the PIC’s operational background, developed almost entirely in rotary wing aviation, it is possible that his limited experience with fixed-wing aircraft had not yet enabled him to acquire the full range of skills and knowledge necessary for the safe operation of Learjet 35 flights.

Following a wrong approach configuration on part of the crew, it was determined that the airplane landed about 600 metres from the runway end. In such conditions, the airplane could not be stopped within the remaining distance.
The following contributing factors were identified:
- Both pilots knew each other well and often flew together, thus it is possible that they over-relied on each other during the final phase of the flight,
- This over-confidence led the crew to neglect certain parameters related to the approach manoeuvre,
- Lack of crew coordination,
- Post-accident medical examinations revealed that the pilot-in-commands' (PF) lack of reaction to the pilot monitoring's (PM) warnings, and his impaired alertness, could indicate that he was suffering from the effects of alcohol and fatigue, reducing his performances,
- The pilots' decision to continue with the landing procedure despite an unstabilized approach characterized by inadequate situational awareness,
- Poor judgment on the part of the crew who failed to take the correct decision to initiate a go-around procedure.

Studies and research showed that the low deceleration of the aircraft and the limitation of the hydraulic pressure provided by the brake system were compatible with a slippery runway scenario. Thus, one inferred that the runway was contaminated, a condition that would reduce its coefficient of friction and impair the aircraft's braking performance, making it impossible to stop within the runway limits. On account of the mirroring condition of the runway in SSDK, it is possible that the crew had some difficulty perceiving, analyzing, choosing alternatives, and acting appropriately, given a possible inadequate judgment of the aircraft's landing performance on contaminated runways.

The following contributing factors were identified:

Attitude – a contributor.
The contribution of the pilots’ attitude to the outcome of this occurrence can be found in two distinct moments: when the go-around procedures were improvised, and when the approach was continued under marginal safety conditions, reflecting difficulties in the way the crew thought and acted.

Communication – a contributor.
One considered that the lack of clear and assertive communication between the pilots at the time of the decision to abort the takeoff, and the lack of definition as to which pilot had the aircraft controls in that moment contributed to the aircraft exceeding the departure end of the runway.

Crew Resource Management – a contributor.
The lack of adequate management of the tasks performed by the pilots during the transition to the takeoff run after the touch-down, a critical moment of the flight, combined with the lack of clear communication between them contributed to the inadequate handling of the aircraft on the ground and its consequent runway excursion.

Handling of aircraft flight controls – a contributor.
The ineffective control inputs during the final approach and during the attempt to stop the aircraft after touchdown, as well as the application of the elevator trim to the opposite side after the touchdown on the runway, indicated inadequacies in the handling of the controls that contributed to the airplane's runway excursion.

Piloting judgment – a contributor.
An inadequate assessment of the parameters related to the aircraft's operation was observed when there was an attempt to abort the takeoff after the airplane had reached 147 knots, without evaluating the remaining runway length to ensure full stop of the aircraft within the runway limits.

Flight planning – a contributor.
One concluded that the flight preparation was not adequately executed, as the planning did not allocate enough time for the pilots to prepare the aircraft for the return and carry-out of the descent procedure, resulting in an unstable approach.

One should not rule out the hypothesis of a possible malfunction of the aircraft's angle-of-attack control system, considering that the records related to the provision of the calibration service (a necessary condition for the proper functioning of the referred system, and prescribed in the aircraft's maintenance manual) were not identified in the pertinent
control documents.