Accident Sequence
At 0650 local time, the aircraft departed from Recife-Guararapes Airport runway 18, destined for Natal with 14 passengers and two crewmembers. During takeoff, after passing the departure end, the copilot informed they would return for landing, preferably on runway 36, and requested a clear runway. The aircraft deviated left, passed over the coastline, then at approximately 400 ft started a right turn over the sea. After about 90 degrees of turn, near the coast, the aircraft reversed to a left turn, moving away from the coastline. After approximately 270 degrees of turn, it leveled its wings and headed toward the airport. The copilot stated over the sea that they would make an emergency landing on the beach. Witnesses reported that as the aircraft crossed the coastline, the left propeller appeared feathered and turning loosely. At 0654 local time, the aircraft crashed into the ground in an area without buildings, between Boa Viagem Avenue and Visconde de Jequitinhonha Avenue, at a distance of 1,740 meters from the runway 36 threshold.
Injuries and Damage
A post-impact fire occurred, and all 16 occupants were killed.
Probable Cause
The official findings list multiple contributing factors:
- Human Factors Medical Aspect: Anxiety, particularly affecting the first officer, which may have inhibited assertive communication.
- Psychological Aspect: Attitude (captain's high confidence and resistance to opinions), emotional state (high anxiety before the emergency), decision making (persistence to land on runway 36 despite conditions), and signs of stress.
- Psychosocial Information: Interpersonal relations (historical differences between pilots), dynamic team (diverging intentions indicating cooperation issues), and company culture (informal division into groups).
- Organizational Information: Education and training deficiencies, organizational culture (informality leading to incomplete training).
- Operational Aspects: Inadequate rudder pedal inputs causing side slip and penalizing performance; captain continued pitch-up inputs despite stall warnings and speed decay below Vmca, leading to stall.
- Crew Coordination: Delay in gear retraction, redundant propeller feathering instruction, and uncoordinated tasks.
- Oblivion: Possible forgetting of the 3rd segment of engine failure procedure due to anxiety.
- Pilot Training: Lack of training for engine failure at or above V1 led to inadequate response.
- Pilot Decisions: Priority to return to opposite runway at 400 ft increased workload.
- Supervision by Management: Failure to identify training deficiencies and that the dispatch software used maximum structural weight (6,600 kg) as MTOW, leading to overweight takeoff and degraded climb performance.
- Mechanical Aspects: Fatigue process in turbine blade of the left engine's gas generator turbine disk.
- Aircraft Documentation: Confusing texts and translation errors in English documentation hindered proper implementation of checklists.