São Paulo

The accident was the consequence of a poor approach planning and wrong approach configuration.
The following contributing factors were reported:
- Deficiencies in crew training,
- Deficiencies in flight controls,
- Poor crew coordination,
- Poor judgment,
- Poor planning,
- Lack of supervision.

The accident was the consequence of the combination of the following factors (findings):
- The imminent interruption of operations in the aerodrome that would be used for landing the aircraft (closure of runway 09R due to works) stimulated the instructor to make a hurried descent, characterizing a potential state of anxiety,
- Probable crew fatigue,
- The instruction given to the pilot was discontinued and the local flight did not comply with the minima provided in RAC 3211,
- The failures found in the instruction were due to poor supervision of the Company's operations sector,
- Poor crew coordination,
- During the descent procedure when working checklist, the instructor broke the sequence of standardized procedures, thus stopping the instruction and consequently, the student's core handling of the flight,
- The instructor, without the student being informed beforehand, commanded the flaps together with the speed brakes. This action configured an abnormal attitude that contributed, without the pilots identifying, to the loss of control of the aircraft,
- The flight engineer also failed to meet the checklist items,
- The instructor did not follow the standardization of the instruction, when he executed a decision in a hurry,
- The crew did not respond to the sinking and pull up warnings,
- Error in the application of flight controls,
- The crew did not operate in accordance with the operational standard issued by the manufacturer and endorsed by the company,
- The air traffic controller contributed to the increase of the crew anxiety level by using non standard phraseology.

The following findings were reported:
- The pilots did not plan the flight properly, though there was an AIS room with the necessary sources of consultation. Maintaining altitude of 5000 feet for too long a time, subject to the minimum safe altitudes in the are area in the available publications, and the discrepancies found in the flight plan confirm this thesis.
- The pilot did not properly collated the guidelines issued by the tower and remained incompatible altitude with instructions issued by the control.
- There are strong indications that the flight proceeded under instrument flight conditions.
- There was no proper coordination between the ACC BS and TWR SJ regarding the transference and control of the air traffic nor did TWR SJ requested receipt of the messages.

Failure of the crew to recognize that he was lined up on a taxiway and not the active runway. Poor visibility due to foggy conditions was a contributing factor.

It is believed that the loss of control was caused by the failure of a blade on the left engine.

The review of all data reveals that upon arrival at destination, the pilots encountered adverse weather conditions. A pilot from the airline, who was near the radio station, informed them that the airport was operating under Instrument Flight Rules (IFR) and that the runway was very wet. Given the intensity of the rainfall, some witnesses believe the airfield should have been closed. The absence of a meteorologist allowed information to be relayed to the crews, who then made unsuccessful approach attempts when they should have diverted to the alternate airport. According to the statement of the captain of the other aircraft flying over the airfield, at the critical moment of the procedure, he had no visual contact with the ground. During the go around procedure, while flying over the airport, he spotted the second half of runway 22, which led him to attempt a visual approach to runway 04. During this attempt, which essentially consisted of a 180° turn, the pilot again sought to establish visual contact in difficult landing conditions (aircraft altitude and immediate proximity of the runway) and aborted the landing. Based on the evidence gathered, it has been concluded that the crew involved in the accident attempted a similar procedure, abandoned the approach and elected to establish a visual contact with the ground. During the final turn completed at low altitude in a steep left bank, despite the crew not having established visual contact, the aircraft struck the ground with its left wingtip and crashed. From the perspective of human error, it should be noted that the pilots had been away from home for five days and that after landing at this airport, they were to complete their mission and be flown back to São Paulo by the second aircraft that was also attempting to land. This situation must have caused them some anxiety about their desire to land, leading them to accept the risks of a perilous operation. The fact that the captain was seated on the right may have contributed to hindering his piloting, allowing the copilot to attempt a visual approach when such a procedure was impossible.

Loss of power on the right engine during takeoff for unknown reasons.

Pilot error.