Varig Flight 254

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**Varig Flight 254**
Summary
Date	September 3, 1989
Type	Fuel exhaustion in flight, Pilot error
Site	Near São José de Xingu, Brazil
Passengers	48
Crew	6
Injuries	41
Fatalities	13
Survivors	41
Aircraft type	Boeing 737-241
Operator	Varig
Tail number	PP-VMK

Varig Flight 254 was a Boeing 737-241, c/n 21006/398,^[1] registration PP-VMK, on a scheduled passenger flight from São Paulo, SP, Brazil, to Belém, PA, on 3 September 1989. Prior to take off from a scheduled stop in Marabá, PA, towards the final destination, the crew entered an incorrect heading into the flight computer. Instead of flying towards its destination, the crew flew due West and after some time found themselves over a remote area of the Amazon jungle. Attempts to reach an alternative airport were unsuccessful, and the plane eventually ran out of fuel. The pilot made a forced landing in the jungle. Thirteen passengers died, and many more sustained serious injuries.

1 Summary
2 Causes
3 After the disaster
4 See also
5 References
6 External links

[edit] Summary

[edit] Early parts of the flight

Flight 254 was scheduled to depart from São Paulo to Belém, and its flight plan included landings on Uberaba, MG; Uberlândia, MG; Goiânia, GO; Brasília, DF; Imperatriz, MA; Marabá, and finally Belém. The São Paulo-Belém route has an approximate duration of eight hours and 20 minutes.

At 9:43, flight 254 left Guarulhos International Airport, São Paulo, heading towards Belém. The flight crew consisted of Captain Cézar Augusto Padula Garcez, 32, First Officer Nilson de Souza Zille, 29, and four flight attendants.

The flight went smoothly through all the stops, and at 17:20, the crew was arranging the final preparations at Marabá airport while the passengers were embarking.

[edit] Moments up to the disaster

While First Officer Zille was making an external inspection of the aircraft, Captain Garcez was consulting the flight plan for the magnetic heading to Belém, which read 0270. This seemed to Garcez to mean 270 degrees, but in reality, it meant 027.0 degrees (Varig's flight plan notation did not explicitly specify the position for the decimal point; which was implicitly located to the left of the rightmost digit). That confusion, along with other minor negligencies, were the primary causes for the disaster. The captain therefore set the left-side Horizontal Situation Indicator (HSI) to 270 degrees, which corresponds to a due West course, clearly inconsistent with a Marabá-Belém leg when one consults a map, but this did not seem to disturb Captain Garcez.

After setting the HSI, Garcez programmed the aircraft Flight management system (FMS) to the distance to Belém (187 nmi (346 km)). The flight plan indicated an altitude of 29,000 feet (FL290), and a leg duration of 48 minutes. When co-captain Zille got to his seat, instead of checking his own flightplan to adjust his HSI (as was his obligation) he limited himself to checking the captain's indicator and setting his to the same parameters. At 17:45, flight 254 took off from Marabá, and the autopilot started a long 158° curve to port, instead of the reasonable 41 degrees heading correction to starboard that should be expected during a normal flight to Belém. It is reported that the mistake may have been due in part to the crew listening to a Brazil v Chile World Cup football qualifying match on the radio.^[2]

When Garcez believed the aircraft to be close to the destination, he attempted to use his VHF radio to communicate with Belém Tower, but failed to do so directly, so he utilized another Varig airliner, RG-266, as a radio relay to be able to talk to Belém Airport. When Garcez managed to communicate with Belém, he requested descent clearance, and received such. Upon performing his descent, the captain found it very odd that he could not recognize any of the characteristic geographical features of the Belém area (such as the Marajó Island and the Amazon River estuary), and even asked the Tower Controller if the city was without electricity. In 1989, Belém airport still had no radar, and so the Controller informed Flight 254 that it was the only one in its airspace, and gave it landing clearance.

After the FMS started indicating negative distance to its destination, Captain Garcez decided to execute a 180 degree turn and locate Belém visually. He also descended the aircraft to 4,000 feet and reduced its speed to 200 knots. Reluctant to utilize the HF radio to request for help, the captain decided to take visual reference from a river he located underneath the plane, believing that river to be the Amazon (actually, it was the Xingu river, and it should be noted that the Xingu river runs chiefly South-North, while the Amazon runs West-East).

At that time, the flight had already taken 30 minutes longer than scheduled, and the passengers were getting anxious. When First Officer Zille finally took notice of their initial mistake, he and the captain decided, after checking their navigation charts, to make contact with Santarém airport (they believed it to be the closest airport in the vicinity), and made an almost 180 degree turn, now establishing a 350 magnetic course. After some calculations, however, Garcez realized that the aircraft did not have the necessary fuel to reach Santarém, and he started heading south again (along the now properly identified Xingu river). Finally, he decided to contact Marabá airport again, to fetch his location. However, the radio frequency of Goiânia locator was the same as Marabá's, and Garcez tuned to Goiânia's locator (Goiânia is located approximately 675 nmi (1,250 km) (780 miles) south of Marabá). The captain was already nervous, and unfortunately he failed to notice that the tuned locator's Morse code identifier was not consistent with Marabá's beacon.

At 20:05, Belém Center called flight 254 again demanding a report. The captain stated that he had a 170 magnetic heading to Marabá (in reality it was Goiânia), and that he was receiving a bearing from the Carajás beacon (which actually was the Barra do Garças beacon). Garcez was perplexed when Belém informed him that the Carajás locator had been shut down since 19:30, and the Center decided to try and illuminate the Carajás runway, in an attempt to facilitate flight 254's orientation. Realizing that he would not have enough fuel to reach Belém, the captain decided to head for Carajás (which would have been the correct decision, had he not mistaken Goiânia for Marabá). On another stroke of bad luck, flight 254 passed, at approximately 20:30, 100 nautical miles (190 km) away from the Serra do Cachimbo Air Force base, which would have been perfectly suited to land the 737, with spare fuel.

After that, it was inevitable that the aircraft would have to make a forced landing over the rainforest in the north of Mato Grosso (at the time, there were no written procedures for such an emergency situation). Garcez and Zille decided to fly at 8000 feet until they ran out of fuel, thus avoiding a possible explosion at the moment of the collision, and with the engines on, they would still have hydraulic power to command the aircraft (devices such as the ailerons and flaps are hydraulically activated). They also decided to keep the plane flying slightly above stall speed, which meant around 150 knots. During their descent, they spotted very few lights through the jungle (which were the houses of farms that had electrical generators). At 20:40, Garcez informed Belém center that he would be making a forced landing over the jungle, and when he had 15 minutes left of fuel, he informed his passengers of the situation. When there were around 100 kilograms (220 lb) of fuel remaining, the left engine stopped. The right engine ran for two more minutes, and then stopped as well.

Even after shutdown, the engines were still windmilling (they rotated simply with the wind passing through). This gave the airplane some rudimentary and unreliable hydraulic control, but that was better than having no power at all. Garcez commanded the lowering of the flaps, which only moved to position Two, or around 10 degrees (due to the failing hydraulic system). With the batteries discharged, there was no electrical power and the only four instruments working in the cockpit were the artificial horizon, the altimeter, the airspeed indicator and the vertical speed indicator. The only thing the crew could see on the horizon were faint light spots due to distant forest burnings, and at 21:06, local time, the plane crash-landed over treetops that extended over 50 m (160 ft) above ground.

The deceleration due to the crash was so intense that passengers without their seatbelts were flung to the front of the airplane, and some seats detached from the floor, also racing forward. When the aircraft fell through the foliage, two thick trees tore away both wings, and caused a severe torsion of the fuselage, which contributed to more seats detaching, and to the collapsing of the false roof over the passenger's heads. After reducing its speed to about 35 knots, the aircraft ran for little more than 30 metres (33 yd) and stopped, lying on its right side.

[edit] Aftermath

Two days later, four of the survivors decided to try to walk and look for help. After three days of walking in the jungle for 40 km, they found the house of the Curunaré farm, in São José do Xingu. That farm had no radio, so they were taken by car to another farm, Serrão da Prata, at 12h30, Tuesday. With the help of radio operator João Capanema Jr., they were able to contact Franca Airport (Franca is a city 400 km north of São Paulo), and on 16:27 of that Tuesday, a Bandeirante airplane from the Brazilian Air Force (FAB) dropped food packages over the wreckage. By 12:00 Wednesday, all survivors had been rescued by FAB.

[edit] Causes

Upon investigation, it was concluded that the crash had been caused primarily due to negligence on part of the Boeing 737's crew. Customary investigations showed that the aircraft was in perfect conditions for the flight, and that its mandatory periodic inspections had been properly conducted.

[edit] After the disaster

The DAC (Civil Aviation Department) recommended that Varig modify its flight plan notation, in order to avoid the decimal point confusion which led to this accident.