São Paulo

Contributing factors:
- Training – undetermined.
The frequent and improper use of the EPL (Emergency Power Lever) during emergency landing training throughout the aircraft’s operation may have contributed to engine degradation.
- Work-group culture – undetermined.
The recurring improper use of the EPL by multiple pilots during the operation of the aircraft may have contributed to engine degradation.
- Handling of aircraft flight controls – undetermined.
It is possible that the pilot's use of the aircraft’s EPL was inappropriate and contributed to the severity of the accident.
- Aircraft maintenance – a contributor.
Given the large number of seat belts that detached as a result of the shearing of their floor attachment brackets and their corroded condition, it was determined that the maintenance actions were not effective in ensuring the integrity and reliability of these materials, which contributed to the injuries sustained by the parachutists during the emergency landing.
- Managerial oversight – a contributor.
The oversight of the operational procedures related to the use of the EPL was not effective in identifying the risks associated with its use in disagreement with the aircraft manufacturer’s specifications.

Contributing factors:
- Attention - a contributor.
The analysis of the pilots' performance during the flight of the previous day revealed episodes of inattention, such as those related to the lowering of the landing gear. In the accident flight, the crew fixated on the excessive RPM, failing to notice in a timely manner that the speed was decreasing, something that limited their ability to promptly respond to the stall condition.
- Attitude - a contributor.
During the accident flight, it was noted that the aircraft rotated at a speed of 102 knots, being such speed consistent with the prescribed aircraft’s maximum takeoff weight. However, because the aircraft’s weight was 1,374 pounds above the MTOW, when it rotated at the referred speed, a continuous 1 kHz alarm sounded, indicating that it had entered a pre-stall condition. Such improvisational approach regarding the MTOW exacerbated the situation, contributing to the outcome of the accident.
Training - undetermined.
The classification of the aircraft by the Brazilian Regulatory Agency as a “class aircraft” may have contributed to the training required from pilots being insufficient to ensure their proficiency in handling emergencies on the B200GT aircraft.
- Work-group culture - undetermined.
According to reports, the belief that the King Air aircraft was capable of taking off with a weight greater than the one specified by the manufacturer was common among operators to whom the investigators had access. This belief may have contributed to the decision made to conduct the flight under those conditions, influencing the takeoff performance.
- Handling of aircraft flight controls - undetermined.
After the retraction of the landing gear, a command to reduce aircraft power was applied by the PIC, which preceded the stall warning. Following this warning, a possible command for feathering one of the propellers may have triggered loss of control of the aircraft.
- Piloting judgment - a contributor.
The takeoff in which the accident occurred was performed 1,374 pounds above the weight limit prescribed in the AFM. Speeds and parameters of a typical takeoff were used, with power being reduced shortly after the landing gear retraction. In this context, there was no adequate assessment of the flight parameters, culminating in the aircraft’s stall condition.
- Aircraft maintenance - undetermined.
Although one engine N2 maximum of 25 RPM greater than the Takeoff and Max Continuous value of 2,000 RPM verified at takeoff cannot be directly linked to the adjustments made to the propellers during the last inspection, the early release of the aircraft may have prevented a sufficiently thorough check of the maintenance tasks performed. This was found to have occurred the day before the accident after the first attempt to start up the engines. There were erasures on the record sheet that documented the engine parameters at entry and exit, leading to discrepancies in relation to the records made in the corresponding Service Order.
- Memory - undetermined.
The analysis of the Cockpit Voice Recorder’s audio spectrum revealed that the propellers were adjusted after the “propeller overspeed” callout was made by the PIC. Although this procedure was not prescribed for the B200GT, it was found to be practiced in the E110 aircraft, in which the PIC had developed much of his professional experience. It is possible that this action originated from the retrieval of previous conditioning, characterizing what is known as “negative transfer”.
- Perception - a contributor.
The stall condition, likely related to the gradual reduction in speed that followed the reduction of the power levers, was not perceived in a timely manner for a reaction to be planned. In that context, there was exclusively a perception of the slightly excessive propeller RPM, a maximum amount of 25 RPM, which impaired the situational awareness regarding the other aspects of the flight.

The accident was the consequence of the combination of the following factors:
- Attention – undetermined.
It is likely that the pilot has experienced a lowering of his attention in relation to the available information and the stimuli of that operational context in face of the adverse conditions faced.
- Attitude – a contributor.
It was concluded that there was no reaction to the warnings of proximity to the ground (Caution Terrain) and evasive action to avoid collision (Pull Up), a fact that revealed difficulties in thinking and acting in the face of an imminent collision condition, in which the aircraft was found.
- Adverse meteorological conditions – a contributor.
The clouds height and visibility conditions did not allow the flight to be conducted, up to SBMT, under VFR rules.
- Piloting judgment – a contributor.
The attempt to continue with the visual flight, without the minimum conditions for such, revealed an inadequate assessment, by the pilot, of parameters related to the operation of the aircraft, even though he was qualified to operate it.
- Perception – a contributor
The ability to recognize and project hazards related to continuing flight under visual rules, in marginal ceiling conditions and forward visibility, was impaired, resulting in reduced pilot situational awareness, probable geographic disorientation, and the phenomenon known as " tunnel vision''.
- Decision-making process – a contributor.
The impairment of the pilot's perception in relation to the risks related to the continuation of the flight in marginal safety conditions negatively affected his ability to perceive, analyze, choose alternatives and act appropriately due to inadequate judgments and the apparent fixation on keeping the flight under visual rules, which also contributed to this occurrence.

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.

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.