An Embraer EMB-110P1 Bandeirante passenger plane, registered PT-SEA and operated by Manaus Aerot xi, was destroyed when it crashed into the water of Rio Manacapuru. Both pilots and 22 passengers were killed in the accident. Four passengers survived. The airplane had departed the Amazon city of Coari (CIZ) at 12:40 on a domestic flight to Manaus (MAO). About 13:10, while at FL115, the no. 1 engine flamed out. At 13:15 the crew made a contact with the Area Control Centre (ACC-AZ) reporting on descent for Manaus with twenty persons on board. In reality there were 28 occupants. The ACC controller instructed the crew to contact Manaus Approach Control. Subsequently, the pilot informed Manaus Approach that they would return to Coari. Contact was lost and at 13:24 radar contact was lost. The airplane came down in Rio Manacapuru. The airplane involved, an EMB-110P1, has a (certificated) maximum number of passenger seats of nineteen. On the accident flight 26 passengers had boarded the flight, including eight small children. Maximum takeoff weight for an EMB-110P1 is 5670 kg. The actual takeoff weight of the accident aircraft was 6414 kg. Contributing Factors 1 Human Factor 1.1 Medical Aspect It did not. 1.2 Psychological Aspect 1.2.1 Individual information 1.2.1.1 – Attitude – undetermined It is possible that the pilot’s stated experience in this type of mission has influenced his permissive attitude towards situations contrary to what was predicted, raising his confidence in the ability to fulfill the mission, thus disregarding the risks involved. 1.2.1.2 – Culture of the working group – contributed There were no mass pilots conducting standardized procedures, such as briefing before and after each mission. They also showed an attitude of acceptance regarding the pilot’s behavior not to carry out the intended procedures. Thus, attitudes were translated into informal rules of behavior in situations related to professional activity and safety. 1.2.2 Organizational Information 1.2.2.1 – Characteristics of the task – undetermined It is possible that the co-pilot took most of the flight preparation tasks in Coari, since it was customary for this to happen on missions with this commander. This may have interfered with the tasks under their responsibility, such as checking the number of people on board and giving passengers guidance on normal and emergency procedures. In addition, it is possible that the division of tasks relating to emergency procedures has been compromised, considering that some switches have been found in positions contrary to those recommended by the operations manual. 1.2.2.2 – Organizational Culture – contributed The company culture was reported as being focused on operational safety, however, in practice, what could be verified did not strengthen safe behaviors. Management did not supervise attitudes and did not control compliance with the procedures covered in the Operations Manual and in company training. There was a small participation of its crew members in prevention activities programmed by the company itself. 1.2.2.3 – Training, training and training – contributed There was no periodicity in training for emergency procedures. Despite the great experience of the commander, the lack of emergency training was present. Training of normal procedures, such as passing proper instructions to passengers, has also not been verified. 1.2.2.4 – Organization of work – contributed The procedures foreseen and established in the company’s Operations Manual for operational safety were not applied, since the crew stopped transmitting the verbal instructions to the passengers, before takeoff and in the emergency situation. The crew made it possible to take off with excess weight and passengers, stopped communicating the emergency situation to the air traffic control agencies and allowed passengers to drink alcohol during the flight, facts that prove the accomplishment of the activities in an improvised way. 1.2.3 – Organizational processes – contributed 1.2.3.1 – Support systems – contributed Through the policy of granting total autonomy to the commander, the company was unaware of the decisions which, consequently, could affect the safety of the flight, as happened in relation to the refueling of the aircraft with less fuel And embark passengers in excess, thus demonstrating that there was no monitoring of activities in the operational scope. 1.2.3.10 – Other – contributed The blockage in the flow of information when the crew omitted information to Air Traffic Control and the lack of information to the passengers, during all the phases of the mission, made the assistance difficult in the face of the situation experienced, because if they had been The consequences could have been minimized. 1.3 Operational Aspect 1.3.1 Maintenance of the aircraft – contributed If the company’s maintenance sector had performed the Oil Fuel Heater temperature check, it probably could have been verified that the thermal element had failed, which would lead to the replacement of the assembly, as recommended by the engine manufacturer’s maintenance manual. It can not be said that such a failure was decisive for the engine failure, but evidence