Varig Flight 254
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| Summary | |
|---|---|
| Date | September 3, 1989 |
| Type | Fuel exhaustion in flight, Pilot error |
| Site | Near São José de Xingu, Brazil |
| Fatalities | 13 |
| Injuries | ? |
| Aircraft | |
| Aircraft type | Boeing B737-241 |
| Operator | Varig |
| Tail number | PP-VMK |
| Passengers | 48 |
| Crew | 6 |
| Survivors | 41 |
Varig Flight 254 was a Boeing B737-241, registration PP-VMK, on a scheduled passenger flight from São Paulo, SP, Brazil, to Belém, PA, on September 3rd, 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 were killed, and many more had serious injuries.
Contents |
[edit] Summary
[edit] Early parts of the flight
Flight 254 was scheduled to depart from São Paulo, SP to Belém, PA, and its flight plan included landings on Uberaba, MG, Uberlândia, MG, Goiânia, GO, Brasília, DF, Imperatriz, MA, Marabá, PA, and finally Belém, PA. The São Paulo-Belém route has an approximate duration of 8 hours and 20 minutes.
At 9:43, flight 254 left Guarulhos International Airport, São Paulo, heading towards Belém. The fligth 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 plane's 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 PMS (Performance Management System) to the distance to Belém (187 nautical miles). The flight plan indicated an altitude of 29,000 feet (FL 290), 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 to starboard heading correction that should be expected from a regular flight to Belém.
When Garcez believed to be close to his 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 mid-point 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 if the city was without electricity. In 1989, Belém airport still had no radar, and so informed flight 254 that it was the only one in its airspace, and gave it landing clearance.
After the PMS started indicating negative distance to its destination, captain Garcez decided to execute a 180 degree turn and locate Belém visually. He also lowered the plane to flight level 04 (4000 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 Xingú river, and it's important to note that the Xingú river runs predominantly North-South, while the Amazonas runs West-East).
At that time, the flight had already delayed for 30 minutes, and the passengers were getting anxious. When co-captain 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 plane did not have the necessary fuel to reach Santarém, and he started heading south again (along the now properly identified Xingú 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 NM south of Marabá). The captain was already nervous, and unfortunately he failed to notice that the tuned locator's Morse code identifier was not compliant 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 Garça beacon). Garcez was perplexed when, therefore, 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 NM away from the Serra do Cachimbo airbase, which would have been perfectly suited to land the 737, with spare fuel.
After that, it was inevitable that the plane 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 of fuel remaining, engine 1 stopped. Engine 2 ran for 2 more minutes, and then stopped as well.
Even after shutdown, the engine fans were still running on windmill (they rotated simply with the wind passing through). This gave the airplane some rudimentary and unreliable hydraulic control, but was better than having no power at all. Garcez commanded the lowering of the flaps, which only moved to position 2, 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 meters 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 plane 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 plane ran for little more than 30 meters 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 hours of walking in the jungle for 40 km, they found the house of the Curunaré farm, in São José do Xingú. 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. On 12:00 Wednesday, all survivors had already 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 (as can be ascertained from the text above). In many occasions the captain could have noticed and corrected his mistake still in time. Customary investigations also showed that the aircraft was in perfect conditions for the flight, and that its mandatory periodic inspections had been properly conducted.
It is interesting to note that a very simple fact could have made that crew notice their mistake very early during the event. When flight 254 took off from Marabá, it started heading directly West, and it was around 18:00. At that time, the Sun was clearly setting, and was visible directly in front of the cabin. If they had been making the correct route, the Sun should be to the left of the plane, which would indicate a proper North heading. The crew, however, failed to notice this rather blatant geographical fact.
[edit] After the disaster
The DAC (Civil Aviation Department) recommended that Varig modified their flight plan notation, in order to avoid the decimal point confusion which led to this accident.
