Juiz de Fora

The following factors were identified:
- The pilot may have displayed a complacent attitude, both in relation to the operation of the aircraft in general and to the need to accommodate his employers’ demands for arriving in SBJF. It is also possible to infer a posture of excessive self-confidence and confidence in the aircraft, in spite of the elements which signaled the risks inherent to the situation.
- It is possible that the different levels of experience of the two pilots, as well as the copilot’s personal features (besides being timid, he showed an excessive respect for the captain), may have resulted in a failure of communication between the crewmembers.
- It is possible that the captain’s leadership style and the copilot’s personal features resulted in lack of assertive attitudes on the part of the crew, hindering the exchange of adequate information, generating a faulty perception in relation to all the important elements of the environment, even with the aircraft alerts functioning in a perfect manner.
- The meteorological conditions in SBJF were below the minima for IFR operations on account of mist, with a ceiling at 100ft.
- The crew did not inform Juiz de Fora Radio about their passage of the MDA and, even without visual contact with the runway, deliberately continued in their descent, not complying with the prescriptions of the items 10.4 and 15.4 of the ICA 100-12 (Rules of the Air and Air Traffic Services).
- The crew judged that it would be possible to continue descending after the MDA, even without having the runway in sight.

The right engine suffered a oil leak in flight following the failure of a hose due to poor maintenance. The following contributing factors were identified:
- Both pilots did not have sufficient experience nor training on this type of aircraft,
- The copilot was flying for this operator for the first time,
- The operator was unable to provide any maintenance documentation nor crew training documentation to investigators,
- Both engines were running at impact but with limited power,
- The right propeller was feathered at impact.

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.