Brazil

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.

Contributing Factors:
- Control Application - contributed.
The difficulty in coordinating the aircraft due to its single-engine flight condition indicated that improper control application contributed to the outcome of this event. Additionally, the early configuration of the aircraft, with the landing gear lowered and flaps at 100%, led it to descend on a glide path below the recommended one, affecting the achievement of the necessary parameters for landing.
- Training - contributed.
The training process previously received by the PIC (Pilot in Command) was insufficient, as it did not provide them with the full knowledge and technical conditions required for performing the duties of a pilot in command of the EMB-121 A1, either due to a lack of training or the low quality of the training received.
- Pilot Judgment - contributed.
The inadequate training led to improper evaluations of the parameters related to the aircraft's operation, contributing to the event. This included a poor assessment of the situation and lowering the landing gear and setting flaps to 100% without ensuring that the landing was secured.

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.

Contributing factors:
- Attitude – undetermined.
The pilot's described profile indicated a characteristic of not admitting personal mistakes and being meticulous in his actions. He likely performed multiple traffic circuits as a way to ensure that the landing gear had locked down, aiming to avoid the consequences of landing with a faulty landing gear, which reflected challenges in his way of thinking, leading to the improvisation of procedures.
- Training – undetermined.
Since the PIC had no simulator training, he may not have acquired the necessary skills for performing the procedures related to the management of the emergency.
- Emotional state – undetermined.
The contribution of a state of tension and stress, due to overload, cannot be disregarded, considering that the PIC faced the need to perform a landing with the possibility of the main landing gear retracting, with his superiors on board, as well as the potential
damage to the aircraft as a consequence.
- Handling of aircraft flight controls – undetermined.
It is likely that improper use of the flight controls during the final approach allowed flight at speeds close to stall speed. Furthermore, it is possible that the controls were not adequately applied to counteract the effects and maintain controlled flight, leading to a sudden left roll of the aircraft and entry into a spin condition resulting from the stall.
- Piloting judgment – a contributor.
Despite being qualified and certified to operate the airplane, there was no adequate assessment of the malfunction and procedures to be adopted during the situation encountered.
- Perception – undetermined.
By focusing all his attention on the landing gear indicator light issue, the PIC may have neglected other procedures due to selective perception or "tunnel vision".
- Decision-making process – a contributor.
There was an inadequate judgment caused by fixation on solving the landing gear indication failure, which affected the analysis and choice of better alternatives for the conditions presented.