São Paulo

Poor approach configuration on part of the crew who landed the aircraft 750 metres past the runway threshold, reducing the landing distance available. The following contributing factors were identified:
- The crew completed an unstabilized approach,
- Poor approach planning,
- Limited visibility due to the night and poor weather conditions,
- The braking action was low because the runway surface was wet,
- The crew failed to initiate a go-around procedure.

The following findings were identified:
- The pilots' perception about the situation was affected by lack of specific training and procedures, which, coupled with the limited time available for action and lack of clarity in communications, influenced the time elapsed for taking corrective actions.
- Communication between the crew was not clear at the time of emergency, making the co-pilot did not understand at first, the action to be performed, which increased the time spent to disarm the CB. Such facts, however, can not be separated from the situation experienced by pilots with inadequate training for emergency and in a short time to identify the problem and take the corrective actions.
- The company had not provided a regular CRM training to pilots. Furthermore, the captain did not receive simulator training for over one year. It was impossible to determine, however, if the regular training and updating of the CRM simulator training of the pilot would have prevented the accident.
- The removal of the pilot from his seat at the time of the emergency may have increased the time spent in identifying the crash and taking corrective actions, but it was not possible to establish whether the accident would be avoided if he would have been in the cockpit. The copilot was slow to understand the situation and initiate corrective actions, although the alarm 'whooler' has sounded, also increasing the elapsed time.
- The operational testing under J IC 27-32-00 allowed the partial completion of the procedures due to lack of clarity, which allowed the release of the aircraft for flight with a defective relay.
Furthermore, although the elevator trim system has been certified, no procedure for emergency triggering of the compensator in the manuals provided by the manufacturer, no replacement intervals of the components of the elevator trim system in "Time Limits" systems normal and reserves were not independent and the system had a low tolerance for errors.

A loss of hydraulic fluids occurred on a hose separating a fitting from a pump on the right engine, causing the malfunction of the primary hydraulic system and resulting in the degradation of the mechanical system of the landing gear control command.

While cruising at FL350, the crew noticed a technical problem with the 'fuel filter' and a 'fuel pressure low' was observed on the right engine. Following a check of the flight manual, the crew reported a fuel transfer issue and attempted an emergency diversion. It was determined that both engine stopped following the rupture of a fuel line connected to the right engine, causing a major fuel leak. The disconnection of the fuel line was the consequence of the rupture of a aluminium ring.

It was determined that the pilot was not qualified to pilot such type of aircraft. Investigations revealed he did not have any licence nor medical documents to prove he was able to conduct such flight with such aircraft. A poor flight planning and a poor evaluation of the weather conditions were considered as contributing factors.

It was determined that the hydraulic pump on the right engine failed in flight, forcing the pilot to shut the engine down. It was reported that the pilot continued the approach in a single-engine configuration without informing ATC and that the aircraft was too high on the glide and approaching with an excessive speed. The pilot improperly analyzed the aircraft's flight conditions after shutting down the right engine, causing the aircraft to enter an approach configuration that was not compliant with the published procedures.

The exact cause of the technical problems on the trim system could not be determined with certainty. The following contributing factors were identified:
- The decisions of the crew and more particularly of the captain during the last phase of flight were incorrect,
- The crew training program for emergency situation was incomplete,
- Improper use of flaps and slats on final approach made the situation worse,
- The captain did not follow the procedure determined for such an emergency situation and decided to continue the approach maneuver, increasing the risk margin and placing the airplane in critical operating conditions,
- Due to deviations from the published standard operational procedures, such as failure to complete the approach briefing and not following the approach checklist, the coordination among the flight crew was poor, leading to further deviations and putting the crew in a critical situation.

The accident occurred in poor weather conditions. It was determined that during initial climb, the aircraft's attitude, speed and altitude varied suddenly and rapidly, causing the pilot flying a stressful situation insofar as he believed that artificial horizons presented technical problems. In such a situation, investigators consider probable the hypothesis that the pilot made inadequate corrections, exacerbating the abnormal situation in which he was operating. The following contributing factors were identified:
- The crew were suffered fatigue because they had been on duty for more than 15 hours and were unable to observe satisfactory rest time at Congonhas airport,
- This fatigue certainly affected the pilots in their decision-making,
- The urge to return home and distrust of instruments in difficult flight conditions seriously compromised the performance of pilots and their ability to make decisions,
- A direct contact with passengers was stressful as they were going through a period of mourning and were eager to return home to Maringá,
- Weather conditions were unfavorable and contributed to the anxiety of the crew,
- Poor assessment of these conditions by the pilots,
- The working time of the pilots exceeded the limitations and the operator did not take into account adequate rest conditions for the crew,
- The training of the captain in instrument flights in recent months was insufficient.

Contributing Factors:
- There was the participation of individual psychological variables in the pilot-in-command's performance due to the excess of self-confidence and self-demand in his customary behavior, besides the dissimulation regarding his real qualification for the type of flight. The personality with traces of permissiveness and insecurity of the co-pilot also contributed to the occurrence, as it allowed the aircraft to be operated by an unqualified pilot, with no employment link with the company.
- There was a lack of adequate supervision by Manacá Táxi Aéreo, as it allowed a crew member who had not operated the type of aircraft for one year and had not made any type of flight for four months, besides not having any employment relationship with that company. It is also necessary to consider the failure of supervision at the organizational level due to the issue of an incorrect license by the DAC, giving rise to the possibility of its use for the revalidation of license in aircraft for which the pilot was not qualified to exercise the function of commander.
- The entire sequence of events began with pilot errors resulting from the pilot's lack of flight experience in the left-hand seat on the aircraft in question.
- The inadequate use of cockpit resources destined to the aircraft operation, due to an ineffective accomplishment of the tasks assigned to each crew member, besides the interpersonal conflict resulting from the co-pilot's intervention in the pilot in command operation, in the final approach phase, already close to the aircraft's touchdown, configure the collaboration of this factor to the accident.
- The inadequate use of the aircraft commands, by the pilot in command, making excessive aileron corrections in the final approach phase, near the landing.
- The pilot was qualified as a co-pilot on the equipment, but due to a typing error, he was issued a pilot license. Thus, the situation and operation of the pilot in question were totally irregular.

The following findings were identified:
- The crew was in a hurry to take off in order to avoid poor weather approaching the airport,
- The crew took off from an intersection with a taxiway,
- Immediately after takeoff, the aircraft entered clouds,
- Approximately one minute after liftoff, the aircraft impacted ground,
- After the first impact, the aircraft flew for another 200 metres and again collided with the ground and exploded,
- The aircraft was totally destroyed by a post crash fire,
- The pilot had a hearing problem that was stabilized and was being researched by HASP. Considering the relationship between ear and ear balance, spatial disorientation in the pilot in
in the face of the adverse conditions it experienced: flight conditions by instruments associated with “windshear”. Since the search could not be completed above mentioned, this aspect remains undetermined,
- Individual characteristics contributed due to the habits acquired by the pilot and his eventual practice of taking off from the taxiway, delaying the point from which the aircraft would achieve the best characteristics flight performance,
- Poor weather conditions with CB's, sudden changes in wind, strong turbulence and rain, were conducive to the emergence of the phenomenon of “Windshear”, representing a real risk to the operation of any aircraft, being that voluntary entry or not, in this type of training, results almost always in the loss of control of the aircraft with unforeseeable consequences. The crew faced these conditions when the aircraft took off,
- It was evident from the witness statements that the pilot was in a hurry to take off, in addition to having used runway 23 from the intersection and towards the sector most affected by poor weather.