Rico Linhas A‚reas flight 4815, an Embraer EMB-120 Brasilia, crashed while on approach to Manaus-Eduardo Gomes Airport, AM, Brazil, killing all 33 occupants. The airplane was on a domestic flight from S?o Paulo de Oliven‡a to Manaus via Tef‚. While 20 nm out of Manaus, air traffic control instructed the pilot to leave the landing pattern to the left in order to give priority to a medical aircraft. The airplane proceeded under radar vectoring and confirmed it had reached 2,000 feet at 18:34. This was the last contact with the flight. The wreckage of the airplane was located at 18:50 about 18 nm from the airport, in a heavily forested area. There were no survivors. Contributing Factors a. Human Factor (1) Physiological ? Did not contribute. (2) Psychological ? Contributed. The accident occurred within the realm of individual psychological aspects and psychosocial variables which, once integrated, indicate a chain of previous events leading to dangerous situations and actions that facilitate the breakdown of routines and doctrines inherent in the prevention of aviation accidents. The human factor was present in the modules of doctrine and standardization, deviation from operational procedures, training and application of knowledge, situational awareness, and prompt response, with variations in motivational, situational, decision-making, and perceptual domains, as well as characteristics related to the personalities of the crew members that influenced the non-conservative attitudes present during the flight. The timing for action was impaired by attention away from the focus, poor communication, ambiguous perception, or failure in the perception of occurrences in the cockpit, and lack of attention in the approach procedure for landing the equipment. b. Material Factor Did not contribute. c. Operational Factor (1) Inadequate Instruction ? Contributed The Training Program was not followed, as the simulator training sessions and LOFT training were not carried out, nor was the CRM course for the crew members renewed. The non-use of these tools greatly degraded the dynamics of the crew and allowed the low situational awareness displayed. (2) Inadequate Maintenance – Undetermined Although no abnormalities in the operation of the autopilot were identified in the crew’s comments, it cannot be ruled out that some malfunction occurred, as had happened on previous flights, due to deficiencies in maintenance services, causing the aircraft to descend below the expected altitude. (3) Inadequate Application of Controls – Undetermined There is a possibility that the crew did not operate the aircraft’s autopilot properly. If such action was carried out, it was not perceived by the crew members, with the deficiency linked to aspects related to training and situational awareness. (4) Inadequate Air Traffic Control ? Undetermined When comparing the message to maintain 2000 ft, the crew generated certainty in the controller about the receipt and compliance of that directive, allowing him to turn his attention to the aircraft carrying the sick person. Thus, it cannot be asserted that such a situation contributed to the accident due to the practically uniform characteristics of the descent profile that the aircraft had been developing until the moment of impact, thus making the participation of this aspect in the accident indeterminate. (5) Inadequate Cockpit Coordination – Contributed The management of activities inherent to the phases of descent and approach did not follow the standardized form established by the MGO. The lack of a descent briefing, the non-performance of the planned call-outs, the incomplete verification of authorizations from air traffic control bodies, the undefined tasks during the descent, and the lack of comments pertinent to alarms allowed the lowering of the crew’s situational awareness. (6) Inadequate Planning ? Contributed The pilots did not perform a descent briefing nor any preparation for the approach and landing to be carried out, allowing inattention to authorized critical altitudes and the non-performance of the planned call-outs. (7) Inadequate Supervision – Contributed Contributions from deficiencies related to supervision in various sectors of the company were verified, which negatively influenced the operational aspects now addressed. The inadequate dissemination and maintenance of an operational culture in line with the principles of Flight Safety contributed to the low situational awareness of the crew – evidenced in the accident – influenced by various aspects within the structure of the company. The non-compliance with the activities planned regarding training and operational performance indicates a lack of adequate supervision in the planning and execution of the Company’s operations. (8) Other Operational Aspects – Contributed As an extension of Inadequate Supervision as a Contributing Factor, it was necessary to characterize the non-performance of actions foreseen in the Company’s Aeronautical Accident Prevention Program – PPAA. The application of the planned Flight Safety Inspection program would increase the possibility of identifying and addressing discrepancies and deficiencies existing in the company, including those related to the training of the crew members.