Brazil

Contributing factors.
- Communication – undetermined
It is possible that difficulties for the dialogue between pilots on matters related to the operation of the aircraft have favored a prejudicial scenario to the expression of assertiveness in the communication in the cabin, interfering in the effective management of the presented abnormal condition.
- Team dynamics – undetermined
It is possible that a more passive posture of the copilot combined with the commander's decisions and actions from the presentation of the abnormal condition in flight interfered with the quality of the team's integration and in the efficiency of the cabin dynamics during the occurrence, bringing losses to the emergency management presented.
- Emotional state – undetermined
It is not possible to discard the hypothesis that a more anxious emotional state of the pilots contributed to an inaccurate evaluation of the operational context experienced, favoring ineffective judgments, decisions and actions to manage the abnormal condition presented.
- Aircraft maintenance – a contributor
On the right engine, it was found that the fuel tube fixing nut that left the distributor for No. 3 cylinder was loose, favoring the fuel leakage, as well as the bypass valve clamp of the turbocharger that was bad adjusted, providing leakage of gases from the exhaust that would be directed to the compressor and, later to the engine, to equalize its power. On the left engine, impurity composed of an agglomerate of soil and fuel were found on the side of the nozzles n° 2, 4 and 6, which migrated to the inside of these nozzles, causing them to become clogged. It was not possible to determine the origin of this material, but there is a possibility that it may have been deposited during the long period the aircraft spent in the maintenance shop, undergoing general overhaul and the revitalization of its interior (13DEC2012 until 29APR2016).
- Insufficient pilot’s experience – undetermined
The pilots had little experience with the GARMIN GTN 650 navigation system. The lack of familiarity with this equipment may have favored the misidentification of the approach fixes for Londrina. This way, it is possible that they have calculated their descent to the final approach fix (waypoint LO013), believing that it was the position relative to threshold 13 (waypoint RWY13).
- Decision-making process – undetermined
The decision to take off from Cuiabá to Londrina without the identification of the reason for the warning light to be ON in the alarm panel and the possible late declaration of the emergency condition showed little adequate decisions that may have increased the level of criticality of the occurrence.
- Support systems – undetermined
The similarity of the waypoints names in the RNAV procedure, associated with the lack of familiarity of the pilots with the new navigation system installed in the aircraft, may have confused the pilots as to their real position in relation to the runway.

The following factors were identified:
- Application of the commands - contributed
There was no effective action on the aircraft controls during the final approach to avoid a brutal impact with the ground prior to the runway threshold.
- Adverse weather conditions - undetermined
It is possible that the aircraft was under the effect of the phenomenon known as windshear, which affected the approach profil and the subsequent impact with the ground short of runway.
- Pilot judgement - contributed
The risks of a possible windshear during the final approach were not adequately considered by the pilot. The decision to proceed for the landing, to the detriment of the alternative recommended by experts to perform a missed approach, proved decisive for the development of the accident.

Contributing factors
- Pilot judgment - undetermined
The absence of manuals and performance charts to guide the operation and actions based only on empirical knowledge about the aircraft may have taken to an inadequate evaluation of certain parameters related to its operation. In this case, the performance of the aircraft under conditions of weight, altitude and high temperatures may have provided its conduction with reduced margins of safety during takeoff that resulted in the on-screen accident.
- Flight planning - undetermined
The informality present in the field of experimental aviation, associated with the absence of support systems, may have resulted in an inadequacy in the work of flight preparation, particularly with regard to performance degradation in the face of adverse conditions (high weight, altitude and temperature), compromising the quality of the planning carried out, thus contributing to it being carried out a takeoff under marginal conditions.
- Project - undetermined
During the PR-ZRA assembly process, changes were incorporated into the Kit's original design that directly affected the airplane's take-off performance. Since the submission of documentation related to in-flight testing or performance graphics was not required by applicable law, it is possible that the experimental nature of the project has enabled the operation of the aircraft based on
empirical parameters and inadequate to their real capabilities.
- Support systems - undetermined
The absence of a support system, in the form of publications that allowed obtaining equipment performance data in order to carry out proper planning, added risk to operations and may have led to an attempt to take off under unsafe conditions.

Contributing factors:
- Application of commands - undetermined
It is possible that the pilot has not acted properly in the controls after touchdown to avoid a runway excursion.
- Flight indiscipline - contributed
Having landed on a non-approved runway, without justifiable reason, the crew member did not comply with the provisions of civil aviation regulations.
- Influence of the environment - undetermined
The wet and puddled runway may have affected directional control and aircraft braking performances during the landing roll.
- Pilot judgment - contributed
The crew member had not correctly assessed the risks involved in the operation in an unapproved runway, without justifiable reason. In addition, the pilot had no considering that the wet and puddle conditions of the runway could affect the directional control and braking performances of the aircraft.
- Decision-making process - contributed
The decision to land at an unapproved aerodrome, as well as having used a wet runway and the presence of puddles denoted an inadequate assessment of the risks present in the context. Failures related to decisions assumed by the pilot contributed to the occurrence insofar as they resulted in the entry of the aircraft into a critical condition, affecting its control.

Contributing factors:
- Application of commands – undetermined
Considering the hypothesis of spatial disorientation, of the disabling type, it is possible that the pilot has reached a situation of complete inability to operate correctly controls the aircraft in order to regain control of the flight.
- Attitude – undetermined
It is possible that the high subordination of the pilot to the requests of his boss has made it difficult for you to position yourself in relation to your limitation in flying at night and in instrument flight meteorological conditions.
- Disorientation – undetermined
Conditions favorable to disorientation, that is, the night flight over the sea, within clouds and manual operation, as well as the dynamics of the aircraft trajectory recorded by the radar, among other factors, make spatial disorientation the main hypothesis for the accident.
- Visual illusions – undetermined
It is also possible that the pilot suffered visual illusions when flying over the sea in night time. When not seeing the lighting on land, and being at night dark, with cloudiness, the pilot may have confused spatial references.
- Instruction – undetermined
It is possible that the lack of familiarity with the English language has made it difficult, in to some degree, knowledge of the resources, equipment and systems present in the aircraft, as well as in the instruction received in a flight simulator.

Contributing factors:
- Attention - undetermined
Moments before the accident, another aircraft successfully completed the landing at the Paraty aerodrome. It is possible that the pilot's attention was focused on this information, which indicated the possibility of landing, despite the critical conditions faced, leading him to take high risks to make the landing in critical conditions.
Also, the presence of a copilot not qualified to operate the aircraft may have influenced the pilot's cognitive processes, causing deconcentration or deviation of attention from the pilot.
- Attitude - contributed
Recurring attempts to make the landing indicated an excess of self-confidence on the part of the pilot, leading him to continue the flight to the Paraty aerodrome, even in adverse weather conditions.
The bold operational profile of the pilot, his past experience and the rules and values ​​adopted informally in the group of pilots are possible factors that influenced the development of this attitude of excessive self-confidence.
- Adverse weather conditions - contributed
On the day of the accident, the weather conditions were not favorable for visual flight at the Paraty aerodrome.
- Culture of the working group - contributed
Among the pilots who operated in the Paraty region, competitive behavior had been installed, valued by the social recognition attributed to those who managed to operate in critical conditions. Above all, landing under conditions adverse weather conditions in the region was considered a manifestation of proficiency and professional competence. The values ​​shared by that group of pilots favored the weakening of the collective perception about the present operational risks. The presence of other pilots who were also trying to land in the region on the day of the occurrence, as well as the landing made by one of these aircraft, moments before the accident, and also the accomplishment of two failed attempts of the PP-LMM aircraft, translates clear evidence of that behavior.
- Pilot forgetfulness - undetermined
The fact that the landing gear was not retracted during the second launch in the air indicated a failure, fueled by the possible forgetfulness of the crew, to perform the planned procedure. Maintaining the landing gear in the lowered position affected the aircraft's performance during the ascent, which may have contributed to the aircraft not reaching the height required to clear obstacles.
- Pilotage Judgment - undetermined
The possible decision not to retract the landing gear during the launch affected the aircraft's performance during the climb, which may have contributed to the aircraft not reaching the height necessary to clear the obstacles.
- Motivation - undetermined
The successful landing by the pilot of another aircraft, even under unfavorable conditions, may have increased the motivation of the pilot of the PP-LMM aircraft to complete the landing, in order to demonstrate his proficiency and professional competence.
- Perception - contributed
The occurrence of a collision with the ground, in controlled flight, indicated that the crew had a low level of situational awareness at the time of the occurrence. This inaccurate perception of the circumstances of the flight made it impossible to adopt the possible measures that could prevent the collision.
- Decision making process - contributed
The pilot chose to make two landing attempts at the Paraty aerodrome, despite adverse weather conditions, indicating an inaccurate assessment of the risks involved in the operation. This evaluation process may have been adversely affected by the competition behavior installed among the pilots. In this context, it is possible that the pilot based his decision only on the successful landing of another aircraft, a fact that limited his scope of evaluation.
- Organizational processes - undetermined
The PP-LMM aircraft was operated by a group of pilots, mostly composed of freelance professionals, who were informally managed by a hired pilot. Therefore, there was no formal system used by the operator to recruit, select, monitor and evaluate the performance of professionals. The failures related to the management of this process, possibly, caused inadequacies in the selection of pilots, in the crew scale, in untimely activations and, as in the case in question, in the choice of crew member not qualified to exercise function on board.

Contributing factors:
- Control skills – undetermined
It is possible that, after inadvertent movement of the horizontal stabilizer, the crewmembers did not operate on the control switches of the secondary pitch trim system, since no other warning sound (Clacker) was recorded on the CVR recordings. The action prevised in the emergency procedures Pitch Trim Runaway or Failure, item 3, regarding trimming of the aircraft through the secondary system, possibly, was not performed. The performance of the crew may have been restricted only to the elevator control on the aircraft controls or to the control of the stabilizer associated with the primary trimming mode.
- Attitude – undetermined
The decision to make the flight without the proper functioning of the primary pitch trim and autopilot system may have been the result of the pilot's self-confidence because of the successful previous flight under similar operating conditions. Considering the hypothesis that the updated Shutdown Checklist, which should incorporate the Stabilizer Trim Backdrive Monitor - TEST, was not performed after the precrash flight, one could consider that there was a lack of adhesion to the aircraft operating procedures. Such an attitude could be associated with the pilot's self-confidence about the aircraft's operating routine, whose acquired experience could have given him the habit of ignoring some of the procedures deemed less important during the flight completion phase.
- Crew Resource Management – a contributor
Throughout the flight, there was an absence of verbalization and communication of the actions on the checklist. Similarly, in the face of the emergency situation of the horizontal stabilizer (Pitch Trim Runaway or Failure), no statements were identified regarding the actions required to manage this situation among the crew. These characteristics denote inefficiency in the use of human resources available for the aircraft operation.
- Training – undetermined
It is possible that the absence of a periodic training in simulator, especially the emergency Pitch Trim Runway or Failure, has affected the performance of the crew, as far as the CVR did not record statements related to the actions required by the abnormal condition experienced.
- Organizational culture – undetermined
The operator did not usually properly fill out the PT-WQH flight logbook. This condition evidenced the existence of informal rules regarding the monitoring of the operational conditions of the aircraft. In this context, it is possible that the history of failures related to the pitch trim system has not been registered.
- Piloting judgment – undetermined
Moments prior to takeoff, it was recorded in the CVR speeches related to the flight without the autopilot, possibly related to a failure or inoperativeness of the primary pitch trim system. The takeoff with a possible failure in the pitch trim system of the aircraft, showed an inadequate assessment of the risks involved in the operation under those conditions.
- Aircraft maintenance – undetermined
It was not possible to establish a link between the maintenance services performed on the aircraft in September 2015 and the events that resulted in the accident occurred on 10NOV2015. However, it was not ruled out that an incomplete crash survey was carried out in the pitch trim system of the aircraft, due to the lack of detail of the service orders.
- Decision-making process – a contributor
The sounds related to the test positions of the Rotary Test Switch have not been recorded in the CVR recording, so it is possible to conclude that the Warning Systems - Check item of the Cockpit Preparation Checklist has not been performed. The decision to perform the flight without the complete execution of all items of the Cockpit Preparation Checklist, prevented the correct verification of the primary longitudinal Trim system of the aircraft and reflected an inadequate judgment about the risks involved in that operation.
- Interpersonal relationship – undetermined
According to the CVR data, there was a possible rush of the crew to take-off, even though it was verified that the aircraft's pitch trim system did not work properly. It was not possible to determine if this rush was motivated by passengers’ pressure or self-imposed by the pilot.
- Support systems – undetermined
It is possible that the Pilots' Abbreviated Checklist - NORMAL PROCEDURES, aboard the aircraft, was outdated, without the incorporation of the Stabilizer Trim Backdrive Monitor - TEST procedure in the Shutdown Checklist. The possible completion of Shutdown Checklist with outdated procedures would have hampered the manufacturer's suggested verification for identification of abnormalities in the aircraft's pitch trim system.
- Managerial oversight – undetermined
The records and control of the operational check flights, both by the maintenance shop and by the operator, prevised in documentation issued by the manufacturer (SB650- 27-53 and ASL650-55-04) were not performed in an adequate manner, indicating possible weaknesses in the supervision of the maintenance activities.

It is believed that the accident was a consequence of a wrong takeoff configuration as the crew did not set the flaps properly.

Loss of control after the crew initiated aerobatic maneuvers at low altitude.