Brazil

Contributing factors.
- Control skills – a contributor
The inadequate performance of the controls led the aircraft to make a ramp that was lower than the ideal. This condition had the consequence of touching the ground before the runway’s threshold.
- Attention – undetermined
During the approach for landing, the commander divided his attention between the supervision of the copilot's activities and the performance of the aircraft's controls. Such circumstances may have impaired the flight management and limited the reaction time to correct the approach ramp.
- Attitude – undetermined
The report that the commander took two photographs of the runway and of the Aerodrome with his cell phone, during the wind leg, reflected an inadequate and complacent posture in relation to his primary tasks at that stage of the flight, which may have contributed to this occurrence.
- Communication – undetermined
As reported by the commander, the low tone and intensity of voice used by the copilot during the conduct of callouts, associated with the lack of use of the head phones, limited his ability to receive information, which may have affected his performance in management of the flight.
- Crew Resource Management – a contributor
The lack of proper use of CRM techniques, through the management of tasks on board, compromised the use of human resources available for the operation of the aircraft, to the point of preventing the adoption of an attitude (go-around procedure) that would avoid the accident, from the moment when the recommended parameters for a stabilized VFR approach are no longer present.
- Illusions – undetermined
It is possible that the width of the runway, narrower than the normal for the pilots involved in the accident, caused the illusion that the aircraft was higher than expected, for that distance from the thrashold 11 of SIRI, to the point of influence the judgment of the approach ramp. In addition, the fact that the pilot was surprised by the geography of the terrain (existence of dunes) and the coloring of the runway (asphalt and concrete), may have led to a false visual interpretation, which reflected in the evaluation of the parameters related to the approach ramp.
- Piloting judgment – a contributor
The commander's inadequate assessment of the aircraft's position in relation to the final approach ramp and landing runway contributed to the aircraft touching the ground before the thrashold.
- Perception – undetermined
It is possible that a decrease in the crew's situational awareness level resulted in a delayed perception that the approach to landing was destabilized and made it impossible to correct the flight parameters in a timely manner to avoid touching the ground before the runway.
- Flight planning – undetermined
It is possible that, during the preparation work for the flight, the pilots did not take into account the impossibility of using the perception and alarm system of proximity to the ground that equipped the aircraft, and the inexistence of a visual indicator system of approach ramp at the Aerodrome.
- Other / Physical sensory limitations – undetermined
The impairment of the hearing ability of the aircraft commander, coupled with the lack of the use of head phones, may have interfered with the internal communication of the flight cabin, in the critical phase of the flight.

The accident was the consequence of the combination of the following factors:
- Control skills – undetermined.
While facing adverse conditions, the use of controls may have been inappropriate for the situation and may have contributed to the aircraft not being able to maintain a positive climb rate.
- Attitude – undetermined.
Familiarization with the region may have led to an attitude, on the part of the PIC, of minimizing the importance of analyzing adverse weather conditions, to the detriment of compliance with the minimum limits established by the company in its manuals.
- Training – undetermined.
It is possible that, due to possible inadequate training, the SIC did not identify the critical situation that arose shortly after the take-off in time to assist the PIC in maintaining flight control.
- Tasks characteristics – undetermined.
The characteristics present in the type of operation, compliance with schedules without the possibility of delays, due to the runway closing period, may have favored the self imposed pressure on the part of the PIC, leading him to operate with reduced safety margins.
- Adverse meteorological conditions – a contributor.
The conditions at the time of the take-off contributed to the aircraft not being able to maintain the flight with a positive climb rate. The probable occurrence of Windshear determined that the trajectory of the aircraft was modified until its collision with the ground.
- Crew Resource Management – undetermined.
On the part of the SIC, no assertive attitude was perceived in the sense of alerting the PIC that those conditions were not favorable for takeoff. Thus, the crew decided to carry out the take-off despite the company's SOP.
- Organizational culture – undetermined.
The company encouraged compliance with the legs even though, within the planning of flights, there was not an adequate margin of time to absorb any delays. This culture may have influenced the PIC's decision-making, which, despite encountering adverse conditions, chose to take off, since the short time on the ground in the intermediate locations did not allow room for delays.
- Emotional state – undetermined.
The reports indicated that the PIC felt pressured to perform the take-off even in the weather conditions found on the day of this occurrence. Also, according to the interviewees, this pressure would be related to the fulfillment of the flight schedule and the need to keep to the scheduled times. In this way, it is possible that their assessment of the performance of the flight was influenced by the stress resulting from the pressure to complete the flight within the expected time, given the closing time of the runway for works.
- Flight planning – a contributor.
The flight planning was not carried out properly, considering that the planned schedules and routes would end after the closing time of the SBEG runway for works, provided for in the NOTAM. This meant that there was little time to adjust the legs, increasing the workload and stress in the cabin.
- Decision-making process – a contributor.
There was a wrong assessment of the meteorological conditions, which contributed to the decision of performing it in an adverse situation.
- ATS publication– undetermined.
The TWR-EG did not inform, before the take-off, of the changes in the significant weather conditions that were occurring at the terminal, which could have contributed to the PIC's decision-making.

The following findings were identified:
- Attention,
- Judgment,
- Perception,
- Management planning,
- Decision making processes,
- Organization processes,
- Support systems.

The following factors were identified:
- Airport infrastructure – a contributor.
It was found that the irrigation pivot, at the point where the collision took place, was impairing the gauge of the approach surface as described in Ordinance 957/GC3, of 09JUL2015, which provided for restrictions on objects projected into the airspace that could adversely affect the safety or regularity of air operations.
- Piloting judgment – a contributor.
The final approach was carried out below the ideal approach ramp, allowing the collision against the pivot, located in the alignment of the runway.
- Perception – undetermined.
It is possible that the PIC, when approaching for the landing, did not notice the irrigation pivot and, therefore, collided with the obstacle.
- Flight planning – a contributor.
There was no prior coordination with the farm employees, in a timely manner so that the irrigation pivot could be repositioned to a safe location in relation to the flight trajectory on the final landing approach.

The following findings were identified:
- The approach was considered stabilized;
- The required landing distance of 6,431t (1,960m) was compatible for the operation, since the LDA of runway 32 at SBFI was 7,201ft (2,195m);
- There was no evidence of malfunction of the aircraft brake system that could have caused the runway excursion;
- At the time of landing, the runway was wet with a significant amount of water on the pavement;
- The estimated deceleration corresponded to what would be expected on a very wet runway (> 3mm of water) with hydroplaning of the tires at higher speeds;
- The friction and macrotexture measurements had normal parameters and did not contribute to the aircraft's poor deceleration;
- The characteristics of the precipitation over threshold 14 associated with the large variations in wind direction and intensity were consistent with the windshear phenomenon, resulting from a microburst;
- The PR-TLZ sensors did not detect the occurrence of windshear during the landing approach;
- A sudden increase in the calibrated speed that peaked at 32kt altered the aircraft's lift and, consequently, reduced the tires' grip on the ground, resulting in poor braking in the parts where the ground speed was lower;
- The speedbrakes were not extended during the run after landing, contrary to what was prevised in the AFM;
- The aircraft ran the full length of the runway, overpassed its limits and crashed into a ravine;
- There was a windshear alert issued about 30 seconds after the landing of the PRTLZ by an aircraft that was at the threshold 32;
- The aircraft had substantial damage; and
- The crewmembers and the passenger left unharmed.
Contributing factors:
- Control skills – undetermined
Despite the low contribution of the speedbrakes to the reduction of the landing distance, this device represents a deceleration resource through aerodynamic drag that should not be neglected, especially during landing on wet runways, and could have contributed to avoiding runway excursion.
- Adverse meteorological conditions – a contributor
The large variation in wind intensity peaked at 32 kt. This variation lasted 13 seconds and raised the indicated speed from 76 kt to 108 kt. Considering that the speed of 108 kt was very close to the VREF (111 KCAS), it can be stated that this phenomenon altered the aircraft's lift and, consequently, reduced the tires' grip on the ground, leading to poor braking.

Controlled flight into terrain.
Contributing factors.
- Attitude - contributed
The fact that the pilot continued the descent visually, not performing the instrument approach according to the IFR flight plan, denoted disregard of the real risks of this action. Thus, his attitude contributed to the inappropriate approach that culminated in the collision with the ground.
- Adverse weather conditions - contributed
Despite the aerodrome presenting ceiling and visibility conditions favorable for visual flight at the time of the accident, it was verified that there was dense fog covering the entire region near the impact site and, therefore, the IFR rules, which determined a minimum altitude of 5,000 ft, should have been observed.
- Emotional state - undetermined
Some events in the pilot's personal life were negatively affecting his emotional state. In addition, the pilot appeared to be more introspective in the period leading up to the accident.
Thus, it is possible that his performance was impaired due to his emotional state.
- External influences - undetermined
The pilot was possibly experiencing difficult events in his personal life. These events could have negatively affected his emotional state.
Thus, the pilot's way of thinking, reacting and performance at work may have been impacted by factors external to work.
- Motivation - undetermined
The pilot intended to return home because he would be celebrating his birthday and that of his stepdaughter.
The audio recording of the pilot's telephony with the GND-FL, shows that he insisted to accelerate his take-off, denoting a possible high motivation focused on fulfilling his eagerness to accomplish the flight. This condition may have influenced the flight performance.
- Decision making process - contributed
The choice to continue the descent without considering the IFR rules, based on an inadequate judgment of the meteorological conditions, revealed the pilot's difficulties to perceive, analyze, choose alternatives and act adequately in that situation.

The pilot intentionally changed his routing for Itapaci where the landing zone was not approved for flight operations. During the landing, the plane struck the ground before the planned zone and crashed. The pilot violated the rules established by the authority.

The pilot descended too low on approach to an umprepared terrain.
Contributing Factors:
- Attitude,
- Command application,
- Pilot judgment,
- Decision making process,
- Lack of adherence to regulations established by the authority of Brazilian civil aviation.