Brazil

The accident was the consequence of the combination of the following factors:
- The crew suffered a spatial disorientation during initial climb,
- The operator was not equipped with effective systems for monitoring and training of personnel,
- Deficiencies in instruction,
- Poor crew coordination,
- The crew probably failed to follow the pre-takeoff checklist,
- Lack of crew experience on the type of aircraft,
- The inadequate assessment of certain operational aspects during the mission and the use of own piloting standards.

It was determined that the right engine failed due to fuel exhaustion, the fuel tank being empty.

The accident was the consequence of the following factors:
- Adverse weather conditions,
- Poor approach planning,
- Poor judgement,
- Poor flight discipline as the crew failed to follow ATC instructions,
- Influence of environment as the region was conducive to the formation of fog,
- The captain had sufficient rest time but his last sleep period was less than five hours,
- The captain was going through a period in which he showed boredom, aggressiveness and demotivation.

The following contributing factors were identified:
• Human Factor - Psychological Aspect - It contributed to the occurrence of the accident due to managerial failures, allowing an aircraft to be used improperly and assigning pilots without the necessary training and experience.
• Deficient Instruction - There are indications that it contributed. Given the errors committed in conducting the flight, regarding incorrect and deficient planning, lack of knowledge or disregard for the limitations of the aircraft, considering the conditions existing at the time of the accident, it is believed that there was deficient instruction during the transition phase from other equipment to this one.
• There was inadequate follow-up during the instruction given to the student, due to the failure to complete the flight evaluation forms.
• Poor Cockpit Coordination - the copilot, by participating in the landing operation merely as a spectator, undeniably demonstrates poor coordination among the crew.
• Poor Judgment - the decision to perform the landing under the existing conditions at the time of the accident (wet runway, excess weight, center of gravity outside limits, etc.) demonstrates a completely deficient judgment on the part of the captain. At the time of the accident, runway 03/21 was 1,303 metres long and in light of the above elements, a distance of 3,285 metres was required for the plane to land.
• Poor Planning - this was the determining factor in the occurrence of the accident, as the failure in weight and balance calculations, as well as incorrect loading, culminated in the loss of control during the landing operation, since the aircraft exceeded all operational limits at that moment.
• Deficient Supervision - despite the commander having extensive flight experience, the number of flight hours on the aircraft type proved insufficient for the role of commander, as the data collected during the investigation showed that he did not possess the necessary technical knowledge, compromising his decisions as commander. The copilot, in turn, was still in training. What the pilot knew concretely, in relation to the mission he was to execute, was only the route to be flown. These aspects are consistent with serious supervision failures and the absence of flight safety doctrine in the company.

The accident was the consequence of a poor approach planning and wrong approach configuration.
The following contributing factors were reported:
- Deficiencies in crew training,
- Deficiencies in flight controls,
- Poor crew coordination,
- Poor judgment,
- Poor planning,
- Lack of supervision.

A. Human Factor
1) Physiological aspect - Did not contribute to the accident.
2) Psychological aspect - The following psychological variables contributed to the accident:
a) Misleading perception - In the reading of the plan and incorrect heading insertion by the commander.
b) Reinforcement - In the reading and incorrect heading insertion by the co-pilot and heading conference placed by the commander.
c) Marginal attention and level of attention - The non-recognition of conditions that would mean being far from the objective: request for "VHF bridge" when other aircraft were talking normally with the Control; "reception" of commercial stations, and non-receipt of destination NDB, etc.
d) Predisposition - Maintaining the urge to go to the established objective (Belém).
e) Predisposition duration - Maintenance of FL040 for a long time.
f) Reinforcement of predisposition - Reception of boundaries when selecting Belem's radio frequencies.
g) Attention Fixing - Permanent search for headings, radio contacts or river contours, as an alternative, to reach the fixed goal.
h) Blocks - Delays in identifying the initial headings error and plotting itself in navigation.
i) Geographical position error.
B. Material Factor - Did not contribute to the accident.
C. Operational Factor
1) Poor supervision - Inadequate graphical representation of the Computer Flight Plan.
2) Poor cockpit coordination - No supervision of cockpit activities. Actions were not supervised, but imitated.
3) Poor support staff - Lack of radio contact by the operator's Flight Coordination with the aircraft in flight, after the significant landing delay in Belém, thus breaking the chain of events of the accident.
4) Pilot aspect characterized by environmental influence - Difficulties of visualization due to sunset and dry fog: Radio aid markings received from great distances, originating from the ionospheric propagation of electromagnetic waves.
5) Pilot aspect characterized by poor planning - Lack of route letters to cross the flight plan information.
6) Pilot aspect characterized by poor judgment - Inadequate evaluation and use of radio-navigation equipment, resulting in the pursuit of markings without causing tuning and identification.
7) Pilot aspect characterized by other operational factors - Operational doctrine firming.

It is believed that the loss of control may have been the result of windshear that existed in the approach path of runway 06.
The following contributing factors were reported:
- The crew did not have sufficient training and experience to manage a windshear situation and thus, was unable to take the appropriate corrective actions,
- Poor crew coordination,
- The captain's experience on this type of aircraft was low,
- Poor supervision,
- Lack of safety culture by the operator.