Air Emergency (2003–…): Season 14, Episode 3 - Varig: Flight 254 - full transcript
Varig Flight 254 was a 737 on its way to Belem, Brazil from Sao Paulo, Brazil. Due to pilot error, it ran out of fuel and crashed into the Amazon jungle.
Request to descend for a final approach
"Boeing 737" heads for a Brazilian airport
on the edge of the Amazon.
Why don't we supposed to be landing in Belem?
I think we are close
But Varig Flight 254
never reaches its destination
Something is very, very wrong here
54 people and a jet-liner
have vanished without a trace.
When the flight did not land,
it was declared an emergency
As they took
the reported position of the airplane,
it wasn't there
The desperate hunt for a missing plane
This is our search area,
right here
will lead to an astonishing find
It is something I am still mystified by
BROKKENPILOTEN
Season 14, Episode 3
This is a true story.
It is based on official reports
and eyewitness accounts
Brazil. in the late 80's.
is a country in transition.
South America's largest nation is preparing
for its first presidential election
in almost 30 years
But today, all eyes are intently focussed
on another contest
Millions of football mad Brazilians tune in
as their beloved team takes on arch rival Chili
in a crucial world-cup qualifying match
That football match was very important
because if Brazil lost
they would be eliminated for the first time
in the world-cup history
The critical match in Rio
is all anyone is talking about
even more than a 1000 miles away
at Maraba airport
where the crew of Varig Flight 254
is getting ready for take off
So, news?
Do you think Chili has a chance tonight?
When it comes to the world-cup
nobody has a chance against Brazil
Varig Flight 254 is scheduled to fly North
from the mining town of Maraba
to Belem, near the mouth of the Amazon river
The crew checks the forecast
and dials in a compass heading
to guide them to their destination
In the 737-200's
which is an older generation airplane
they don't have
the modern flight management computers
They use an older technology
of ground-based radio navigation-aids
There are 48 passengers on board,
including Carlos Siqueira
I was taking time off
I worked for a mining company in Maraba
and I was returning home to my city of Belem
Here we go
Captain Cezar Garcez
is flying the airplane tonight
while first officer Nilson Zille
monitors the instruments
Rotate
At 5:35 PM, the Boeing 737 gets airborne
It was a very routine flight
It was a clear day
There were no weather issues
There wasn't any reason for them to be worried
about anything
The flight should take less than an hour
Since I worked in Maraba,
I usually took that flight every 20 days
After 23 minutes,
the flight-computer tells the captain
that they are getting close to Belem
This airplane had
the Performance Management system
where they could enter the distance
to the destination
and it would help improve the fuel efficiency
The pilots try
to contact controllers on the ground
Belem Tower, Varig 254
requesting descend
Strangely, they get no response from the tower
Belem Tower, Varig 254
Belem Tower,
do you read?
Let me try
The pilots, I think,
would have been surprised
first: Do they have a communication radio problem?
Why can't they talk to Air Traffic Control
Airports are equipped with
VHF omni directional range beacons
or VOR beacons
They send out signals
that planes follow to the runway
I've got nothing
Varig 254 isn't picking up the signal
from Belem Airport
I'll call the Tower on HF
The Captain switches his radio to High Frequency
and tries making contact again
Belem Tower,
Varig 254
They were not able to raise ATC
on their VHF communication radios
It happens occasionally
and it requires then the use
of a much longer range radio system
Belem Tower, Varig 254
The strategy works
Varig 254,
Belem tower, go ahead
As you approach the destination
you have radio navigation tuned up
to that specific beacon on the ground
Belem,
we are on approach but we don't see the VOR
Is the beacon down?
Negative, 254,
it looks like it is on your
In this case they weren't receiving that
and they were doing what is
deduced reckoning or dead reckoning
The captain checks
his Performance Management System
and calculates
when they will arrive at their destination
Belem, we are 25 minutes out
Request for final approach
Roger, Varig 254,
cleared to flight level 20,000 ft
The controller clears the crew down to 20,000 ft
Flight level 200, Varig 254
Air Traffic Controllers in non-radar environment
separate the airplanes by time
So, these position reports are very critical
and they require if you estimate to a fix
changes by more than 3 minutes
you require to advise ATC of that revised estimate
The plane should soon be at the airport
When the plane was descending
it seemed like it was a normal landing
As the plane drops below the clouds,
the captain looks for the lights of Belem
They break out of the clouds,
expecting to see terrain they are familiar with
where are the lights?
and expecting to see the airport
and to visually align the airplane
with the landing runway
They don't see that
Instead, there is only darkness
as far as the eye can see
That is when everybody thought:
Where is he going to land if there is no runway?
Belem is not there
Aren't we supposed to be landed in Belem?
Panic started building in the airplane
People were asking:
Why aren't we landing in Belem?
What is going on?
Wait a minute,
I think we just overshot the airport
The crew may have discovered the problem
The PMS shows that they flown 30 miles
past their destination
You do want to a 1A
Yeah, turn right, heading 090
The crew really begin to realize:
OKAY, we've made a small navigation mistake
We need to find the airport
and go ahead and land
The pilot didn't offer any explanation
He simply proceeded to manoeuvre and turn around
And it was already night-time.
Belem, we are very close
requesting further descend to flight level 4000 ft
254,
You are cleared for descend flight level 4000 ft
The controller clears the plane to descend further
to 4,000 ft
The captain expected he would be landing in Belem
in about 5 minutes
On the football pitch,
Brazil has taken the lead
Their goal of reaching the World Cup is in sight
But in the air
No visual lights, captain
the pilots of Varig 254
are no closer to finding the runway
Their actions indicate a slow realization
that they are not where they think they are
What is our fuel?
Now the question arises:
what are they going to do about it?
At Belem Airport,
the controller is growing concerned
Flight 254 should have landed 10 minutes ago
No visible lights, captain
They knew now there was a serious problem
When the flight didn't land
it was declared an emergency
On Flight 254, the situation is becoming critical
We need to land soon
or soon we are running out of fuel
I think we are close
When he flew over where he thought Belem should be
he didn't find it
It is very easy to find Belem
He didn't understand what was happening
Why don't we see if we pick up
a local radio-station from Belem?
The captain tries to home in
on a local radio signal
hoping it will help guide them toward the city
The automatic direction finders, or ADFs
are capable of tuning up
commercial AM radio stations
and that would have been very critical,
because this is a low population area
there is not a lot of geographic visual clues
We are talking about the Amazon
The do or die match is being broadcast
by radio-stations all across the country
Brazil leads 1-0 with 20 minutes to go
when suddenly controversy erupts on the field
One of the fans threw a flare,
that fell right next to the Chilean goalie
The goalie pretended that the flare hit him
and cut himself with a razor blade
His face was covered with blood
and the Chilean team abandoned the field
If Chili left the match for security reasons
they could be declared the winners of the match
Aboard Flight 254, the pilots have managed
to pick up a local station, broadcasting the match
Now we can follow the signal towards Belem
Turning right, heading 165
Passengers cannot understand
why the plane is turning yet again
We were getting extremely worried
The plane is going back and forth
The stars and the moon were on one side
and now they are on the other side
There is something wrong here,
what is going on?
The Captain is confident he is now on course
he spotted a landmark on his radar
There we go!
We are over the Amazon now
Belem is near the mouth of the Amazon
following the river
should lead the pilots to the city
but moments later, there is serious trouble
We've got a fuel warning
Flight 254 is running out of fuel
The pilots suddenly realize
they cannot make it to Belem
Do you want to put up flaps in case we lose power?
They will have to crash land
in the dense Amazon rainforest
Flaps to 2
We need to do a controlled descend
I'd better prepare the passengers.
Ladies and gentlemen, we have a malfunction
with our navigation instruments
and we will be making a forced landing
He said that there is going to be a forced landing
and that we should all take
our emergency positions
Bend your head down
and hold your legs together
and may God help us
those were his words
Panic begins to take hold in the cabin
Some people were praying
Others waited the bar and drank everything
Others were looking for the best spot
in case of a crash
Another passenger sat in the last row
He grabbed all the pillows
and completely covered himself with them
At 8:45 PM, Flight 254 runs out of fuel
The left engine is the first to die
We just lost an engine
Hang on
I am going to put her down
There goes the other one
With the 2nd engine gone
the 37 ton jet sinks closer and closer
to the ground below.
You have your eyes closed,
your life flashing before you
You ask God forgiveness
for all the wrong things you did in your life.
The inevitable impact is just seconds away
I just need to bring us down!
nice and slow
Then, what happened
was it started to touch the top of the trees
You are expecting the worst
He made the most difficult forced landing
in the history of aviation
meu deus no céu
When the plane stopped
I felt myself all over
to see if I had any cuts
or broken bones
And then I thought:
Am I in heaven?
Have I died and already in heaven?
Of the 54 passengers and crew
48 have survived
Many are badly hurt,
including first officer Zille
The First Officer Nilson Zille
was pierced on one side by a tree-branch
He was badly injured
He fractured his leg and his shoulder
Captain Garcez quickly takes control
of the situation
Captain Garcez didn't get hurt,
he didn't even have a scratch
At that point Garcez did everything
a captain must do
He helped those that he could help
He freed whoever he could,
those who were trapped in the metal debris
We have to get you
out of here, OKAY?
Can you hear me
Surviving the crash-landing feels like a miracle
to many of the passengers
But they now face a new threat to their survival
They are stranded in the vast Amazon rainforest
with no food, no water
and no guarantee that they will ever be found
The shattered fuselage of a 737
is now the only shelter
for survivors of Varig Flight 254
The plane's sudden disappearance
over the Amazon rainforest
has left Brazilian Aviation authorities
grasping for answers.
They turn to Colonel Ronaldo Jenkins
an air-crash investigator
with the Brazilian Air-force
They called me and said:
There is a commercial aircraft that was supposed
to arrive in Belem and it didn't arrive.
but no one knew exactly what happened to the plane
They left Maraba on time
but never got to Belem
This is our search area,
right here,
The first challenge is to look at the aircraft
I figured out the best way to reach it,
because initially, we weren't sure where it was.
Investigators interview the last person
to be in contact with Flight 254:
the Belem Air Traffic Controller
According to the controllers,
the communications were quite normal
Other than the strange fact,
that they weren't receiving a signal
from the ground based equipment,
the VOR beacon at Belem
He said he was close,
He asked me for descend
Belem Airport is not equipped with radar
The controller can only tell investigators
the pilot's last reported position
Because there was no radar,
the ATC relies on the proper navigation skills
of the pilots and their timely reports
With little else to go on,
rescuers concentrate the search
in a small radius around Belem.
They find no sign of Flight 254
You never start with a pre-conceived idea
that such and such happened
explode in mid-flight...
...lost an engine, non of this.
In other words: you go and search
of the aircraft that left one location
and is supposed to arrive in another
Investigators also comb through satellite data
hoping to find a signal
from the plane's emergency transmitter.
The distress beacon is designed to activate
after an accident
to help guide rescuers to the plane
The impact should have set off their locator
All we have to do,
is figure out which one is Flight 254
But the signal from those beacons is on the
same frequency as other emergency transmissions
making it hard to pin-point the plane
Every time you use this frequency,
or speak on this frequency
the satellite receives those messages
and so, it is a lot of work to identify which one
is the real position of the airplane
Meanwhile, somewhere in the Amazon rainforest
the survivors of Flight 254 are struggling
to stay alive
I was part of a group
and went out to search for water
There was a stream nearby,
we drank some water and we took some back
for the people who are in the plane
But Carlos Siqueira's efforts cannot save everyone
There were people there who were severely injured
and in horrific pain
and some of the passengers started dying
If help doesn't arrive soon,
more will die
The Captain had hoped, rescuers from Belem
would find the crash site within hours.
Now, a day later, he fears the plane's
emergency beacon isn't sending out a signal
It is working if I just can get it submerged
Some beacons are designed to activate only
when a plane is lost at sea
In the case of the Varig airplane,
it was the emergency locator transmitter only
transmitted when it was emerged in water
With precious water in short supply,
Garcez comes up with a creative solution
They urinated on it to submerge it
so, that it would be activated
I want to send a helicopter to go and confirm
the identity of this signal...
...here
You get anxious to find the plane quickly
because people have a better chance of survival
during the first 48 hours.
After that, survivors are more likely to die
After two nights in the jungle
the survivors realize
they cannot afford to wait to be rescued
People were weak, because we had water,
but no food.
Good luck!
A small group sets of in the jungle to find help
Hours later, they stumble on a farmhouse
Their terrifying ordeal will soon be over
They found survivors
It is a relief to realize
the scenario is not as tragic
and there is an urgent desire
to get to the location and start to work
Then, investigators get a shock
The crash-site is nowhere near Belem
It came down, right...
...here
The wreckage of Flight 254 is lying in the jungle,
nearly 700 miles away
I got heard they get way over there
We were really very surprised to learn
that the plane was in that location
Very far South, and very far West
of the position where it should have been
I wonder we can spot the beacon
It is no where near the destination
As search and rescue-team
scramble to the remote location
investigators are left with an urgent question
They were not supposed to be in that location,
so they got lost during the flight
Now, what caused them to get lost
continues to be a mystery
The Brazilian military reaches
the remote crash site of Varig 254
The survivors are air-lifted out
5 have died waiting for rescue,
another dies soon after.
There were some people who died,
not during the crash
but because they didn't get any medical aid
Many believe more would have died,
if not for the skill of Captain Garcez
Garcez was considered a great hero
by the Brazilian people
because he was the pilot,
he was able to land the plane in the dark
and saved 42 out of 54 passengers
I know this guy
He is a good pilot
Investigators are puzzled how a pilot
as accomplished as Garcez
could have flown so far off course
While I worked as an inspector for Varig
twice I oversaw Garcez
Twice!
and I could see
that he was a very disciplined pilot
and extremely professional
He knew the aircraft, knew the procedures
He definitely did things correctly
Our navigation instruments weren't working
It is very strange
I'd never encountered something like this before
The Captain claims
the plane's instruments malfunctioned
He was forced to navigate
by tuning in to a radio station
We had to improvise
News that the crew tuned in
to a commercial radio station
sparks media speculation that
the pilots became lost
because they were distracted by the match
You hear a lot of things
during an accident investigation
a lot of ungrounded speculation
I would call that
an incomplete and unsubstantiated accusation.
At the Amazon crash site,
there has been a major break-through:
the discovery of the plane's two flight-recorders
The FDR captures detailed information
about the plane's heading
Investigators hope it will reveal why Flight 254
was so badly off course
we were relying on the two recorders
Both pilots were alive
so we thought we were certain
to come to a conclusion
They also recover as many documents
from the cockpit as they can
The most important things at that moment
were navigation charts...
...all of them.
Manual, records, anything
that would provide support and guidance
for the pilots to fly the plane
Each fragile page is carefully photographed
to prevent further damage
Meanwhile, investigators use the heading data
to reconstruct the path of the plane
They took of due West,
heading 270
The Flight Data Recorder was fundamental,
it provided us with the track of the airplane
the positions, the times...
...where the airplane flew
But the flight data paints a confusing picture
Instead of flying North to Belem,
the plane took of West
and flew in the wrong direction,
throughout the flight
They were flying
the wrong way for the entire flight
This became a central focus of the investigation
to know why the aircraft was so far off course
A broken navigation system
could explain the mistake
but when the investigators try to get
more information from the crew
they hit an unexpected roadblock
The pilots union
flies Garcez and Zille to Rio de Janeiro
denying investigators access to them
for several days
The Union believed the investigators
would hold the pilots responsible for the crash
For now, the only words from the pilots
that investigators can hear
are those, captured on the CVR
Let's hear it!
We just lost one engine
do bring us down
nice and slow
It is the hardest part of the job
for any air crash investigator
Hearing the fear in a pilot's voice
We just lost the other one!
and listening, as a fatal tragedy unfolds
Rewind it please,
all the way to the beginning
Investigators hope, the 30 minute recording
can tell them why the pilots
flew in the wrong direction
But they are out of luck
We are over the Amazon now
By the time the recording starts,
the pilots are already badly lost
Whatever led them off course,
happened earlier in the flight
CVRs traditionally have been
the last 30 minutes of flight
Only in recent years has that recording length
been extended to 2 hours
The problem started
during the first moments of the flight
We didn't have a recording,
because of the time-limitations of the CVR
Investigators are desperate for more information
They study the navigational instruments,
recovered from the cockpit
we sat out to make a complete analyses
of the entire navigation system of the aircraft
They know the captain reported
a malfunction in the navigation system
that puts his plane hundreds of miles off course
The need to figure out what could have caused
such a malfunction
if they don't, the lives of passengers
around the globe could be in danger.
We were very concerned,
because there were at least 30 other
aircraft of the same model flying in Brazil
If it happened to one,
it can happen to others
The pressure on investigators is huge.
Investigators look into the possibility
that the navigation system on
Varig Flight 254 malfunctioned
and led the crew off course
In a situation where there is this much confusion
about where they are
one of the questions that come up is
what systems have may have malfunctioned?
They suspect the plane's cargo may hold the key
The 737 has a magnetic sensor in the tail
that acts as the plane's compass
It tracks which direction the plane is flying
and feeds that information
to the cockpit instruments
If something in Flight 254's cargo
was giving off a strong magnetic field
it might have confused the sensor
we studied every aspect of the cargo
even things that might have
been on the shipping pallets
that might have influenced
something in this regard
They also test
every component of the navigation system
and check for any sign of failure
but they find nothing in the cargo
that could affect the compass
and the instruments are working perfectly.
we verified that there was nothing that
might have caused the electromagnetic interference
Nothing that could have changed the heading...
...or influence the change of course
Investigators catch a break
Flight 254's flight-plan
has been recovered from the cockpit
Airlines provide flight-plans to every crew
It contains critical details
about the route they should fly
including the heading they are meant to take
Let us see what this will tell us
The airline provides a detailed flight-plan
in a computer printout to the flight-crews
This provides a series of waypoints
that they are to look for to fly the ground-track
But what if the airline
gave the pilots a faulty flight-plan
One that send them in the wrong direction?
This could be the lead they have been waiting for
I think I know what they did wrong
A close look at Varig 254's flight-plan
provides a revelation
In this particular case with the Varig Flight
Very unusually, their computer flight-plan system
has 4 digits
This is very, very unusual
as they almost always have only 3
The numbers 0270 was intended to mean
27.0 degrees
When we noticed that, it gave us the idea
that instead of entering 027
which was the heading to Belem
he had entered 270
He was supposed to fly North,
heading 027
The captain read it as 270 degrees,
or due West
So, instead of flying North-East
they went West, instead
he entered the wrong heading
He set the airplane up to depart West
270 degrees or due West on the compass
is more than 240° passed the Northerly heading
of 27° they were given
The moment of truth arrives
when they call Captain Garcez back in
to give his side if the story
I'll try to help you,
but I think I told you everything you know already
We told Garcez:
Look, we have the on-board charts
We have the tapes and all of the documents...
...verified by us
What is the truth
(O que é a verdade)
At first the captain is reluctant to admit
he made a mistake
We said:
Garcez, tell us the truth
You didn't have a problem
with the navigation instruments, did you?
Under intense questioning, Garcez finally admit
he misread the flight-plan
Look, it was an honest mistake
From that moment on,
the cause or the basic framework of the accident
was determined
Investigators learn the airline began
printing their flight-plans this new way,
while the captain was on vacation.
It is easy to see
how you get confused
Varig had bought some more sophisticated planes
which had instruments that accepted decimal places
But that wouldn't mean anything on this flight
since the Boeing 737-200
didn't have decimal places
But there is another question
The first officer must also enter the heading
from the flight-plan
So, Nilson,
do you think Chili has a chance tonight?
Why did he make exactly the same mistake
as the Captain
Aviation psychologist Kathleen Mosier
has an answer
The copilot,
probably after many experiences with captains
who had always done it right
and never have to double-check
just entered what the captain had put in
and assumed that was the right thing
So, in this case, your safe-guarding is gone,
because the copilot is not cross checking
He could have caught this mistake
before they took off
Once you take of,
the automation does what you told it to do
Varig 254 takes off due West,
instead of North...
...straight into the setting sun
It is an incomprehensible error
Do you not realize
that you are flying into the sun?
That should have been a big cue
They must have been very confident
that they had done the right thing
The two pilots disagree about
how things went wrong
We need to land soon
or we are going to run out of fuel
I think we are close
The first officer was protecting himself,
suggesting that he had done everything right
and Garcez was at fault
The original navigation mistake
was that of the captain
The failure to independently verify
was a mistake on the part of the first officer
What is disheartening here
is that both pilots went along with it
It is now all too clear that Flight 254
was flying in the wrong direction
from the moment it took off
A mistake even some passengers noticed
Well, we thought the person in charge here
is the captain
At least three of the passengers
warned the flight attendance
that the plane was flying
in the wrong direction
but the flight attendance thought:
Well , the Captain knows more about this
and they didn't reach Garcez to warn him
that he was flying in the wrong direction
We thought that, up in the sky,
the captain is in charge, so
But it is what the captain does next:
to turn his error into a catastrophe
The crew of Varig 254 makes
a critical error in judgement
We decided to tune in to a radio station
Instead of radioing for help,
they try to get back on course
without admitting their mistake
His pride prevented him
from saying to his colleague:
Help me, I am in trouble
That would have been a better approach.
Their attempt to use commercial radio-station
to find the airport...
...doesn't help.
They wrongly assumed
the signal is coming from Belem
they follow it away from their destination
When you tune into a commercial radio broadcast
it is possible to receive content,
originated from different locations
Garcez, can you believe this?
They still haven't restarted the match
You need to verify that it is in fact that station
that it identifies its call letters
and that you have that validation
Can you believe those guys?
Though there is no hard evidence,
some continue to believe
the pilots were distracted by the football match.
People say:
He was listening to the Brazil-Chili match
and that is why he didn't notice his mistake.
But investigators believe
there may be a psychological explanation
A quirk of human nature that can trap
even the best trained pilots
There we go,
We are over the Amazon now
The captain spotted a river
A river that he thought was part of the Amazon,
North of Belem
you decide on your initial judgement
and you think that it is right
and so, you look around for things
that support your position
The crew was looking for signs
that they were close to Belem
He decided to follow that river South,
to get to Belem
But the river they saw was not the Amazon
It was the Xingu,
a river more than 600 miles South-West of Belem
they were so confused for so long
Investigators conclude the crew was in the grip
of what is know as confirmation bias:
the tendency to favour information
that confirms something we already believe.
I think we are close
Confirmation bias is one of
the common decision making biasses
that people are subject to
the thing is that you don't often recognize
that is what you are doing
When I saw the river I was sure
I was sure we were close to Belem
This case show you
anybody can fall into decision traps
even experts have to always be on guard
In 3+ decades of doing accident investigation
this is one of the most unusual accidents
I have ever read or am aware of
The accident-report faults
both pilots for the disaster
As the details of the flights were discovered,
the terrible mistake that he made
the captain went from hero to villain
They were both convicted for their negligence
and sentenced to community service
The report also criticizes the Belem controller,
for not raising an alarm sooner
The controller at Belem tower
was very worried about the football match
between Brazil and Chili
He had one ear on the broadcast of the match
and the other paying attention to the flight
254, you are cleared for descend
He should have realized
there was a problem
when the plane could only
contact the tower on HF radio
A major clue that the plane is probably far away
Everybody makes mistakes,
errors are not unavoidable
The way that you deal with this
is that you be aware of the threat
You try and trap errors,
if they occur, and fix them
I think it was the failure
of these two pilots
to maintain the highest standards
of professional airmen-ship
I think, in that point,
they did not meet the necessary mark.
After the crash of Varig 254
the airline changes their flight-plans
So the decimal place is clearly marked
They also improve pilot training
Brazil's national radar system is modernized
and expanded to cover the entire country
making it less likely that a plane will go missing
Brazil never even made it
to the quarter finals of the 1990 World Cup
which was won by West Germany
The scandal of the Brazil-Chili match
faded over time
But the legacy of Flight 254 endures
This is one of those cases we are looking and
understanding what this crew did
can serve as an
absolute bright example
to help crews in the future
not make these same mistakes
Narrator
Jonathan Aris
Subtitles
Rein Croonen
"Boeing 737" heads for a Brazilian airport
on the edge of the Amazon.
Why don't we supposed to be landing in Belem?
I think we are close
But Varig Flight 254
never reaches its destination
Something is very, very wrong here
54 people and a jet-liner
have vanished without a trace.
When the flight did not land,
it was declared an emergency
As they took
the reported position of the airplane,
it wasn't there
The desperate hunt for a missing plane
This is our search area,
right here
will lead to an astonishing find
It is something I am still mystified by
BROKKENPILOTEN
Season 14, Episode 3
This is a true story.
It is based on official reports
and eyewitness accounts
Brazil. in the late 80's.
is a country in transition.
South America's largest nation is preparing
for its first presidential election
in almost 30 years
But today, all eyes are intently focussed
on another contest
Millions of football mad Brazilians tune in
as their beloved team takes on arch rival Chili
in a crucial world-cup qualifying match
That football match was very important
because if Brazil lost
they would be eliminated for the first time
in the world-cup history
The critical match in Rio
is all anyone is talking about
even more than a 1000 miles away
at Maraba airport
where the crew of Varig Flight 254
is getting ready for take off
So, news?
Do you think Chili has a chance tonight?
When it comes to the world-cup
nobody has a chance against Brazil
Varig Flight 254 is scheduled to fly North
from the mining town of Maraba
to Belem, near the mouth of the Amazon river
The crew checks the forecast
and dials in a compass heading
to guide them to their destination
In the 737-200's
which is an older generation airplane
they don't have
the modern flight management computers
They use an older technology
of ground-based radio navigation-aids
There are 48 passengers on board,
including Carlos Siqueira
I was taking time off
I worked for a mining company in Maraba
and I was returning home to my city of Belem
Here we go
Captain Cezar Garcez
is flying the airplane tonight
while first officer Nilson Zille
monitors the instruments
Rotate
At 5:35 PM, the Boeing 737 gets airborne
It was a very routine flight
It was a clear day
There were no weather issues
There wasn't any reason for them to be worried
about anything
The flight should take less than an hour
Since I worked in Maraba,
I usually took that flight every 20 days
After 23 minutes,
the flight-computer tells the captain
that they are getting close to Belem
This airplane had
the Performance Management system
where they could enter the distance
to the destination
and it would help improve the fuel efficiency
The pilots try
to contact controllers on the ground
Belem Tower, Varig 254
requesting descend
Strangely, they get no response from the tower
Belem Tower, Varig 254
Belem Tower,
do you read?
Let me try
The pilots, I think,
would have been surprised
first: Do they have a communication radio problem?
Why can't they talk to Air Traffic Control
Airports are equipped with
VHF omni directional range beacons
or VOR beacons
They send out signals
that planes follow to the runway
I've got nothing
Varig 254 isn't picking up the signal
from Belem Airport
I'll call the Tower on HF
The Captain switches his radio to High Frequency
and tries making contact again
Belem Tower,
Varig 254
They were not able to raise ATC
on their VHF communication radios
It happens occasionally
and it requires then the use
of a much longer range radio system
Belem Tower, Varig 254
The strategy works
Varig 254,
Belem tower, go ahead
As you approach the destination
you have radio navigation tuned up
to that specific beacon on the ground
Belem,
we are on approach but we don't see the VOR
Is the beacon down?
Negative, 254,
it looks like it is on your
In this case they weren't receiving that
and they were doing what is
deduced reckoning or dead reckoning
The captain checks
his Performance Management System
and calculates
when they will arrive at their destination
Belem, we are 25 minutes out
Request for final approach
Roger, Varig 254,
cleared to flight level 20,000 ft
The controller clears the crew down to 20,000 ft
Flight level 200, Varig 254
Air Traffic Controllers in non-radar environment
separate the airplanes by time
So, these position reports are very critical
and they require if you estimate to a fix
changes by more than 3 minutes
you require to advise ATC of that revised estimate
The plane should soon be at the airport
When the plane was descending
it seemed like it was a normal landing
As the plane drops below the clouds,
the captain looks for the lights of Belem
They break out of the clouds,
expecting to see terrain they are familiar with
where are the lights?
and expecting to see the airport
and to visually align the airplane
with the landing runway
They don't see that
Instead, there is only darkness
as far as the eye can see
That is when everybody thought:
Where is he going to land if there is no runway?
Belem is not there
Aren't we supposed to be landed in Belem?
Panic started building in the airplane
People were asking:
Why aren't we landing in Belem?
What is going on?
Wait a minute,
I think we just overshot the airport
The crew may have discovered the problem
The PMS shows that they flown 30 miles
past their destination
You do want to a 1A
Yeah, turn right, heading 090
The crew really begin to realize:
OKAY, we've made a small navigation mistake
We need to find the airport
and go ahead and land
The pilot didn't offer any explanation
He simply proceeded to manoeuvre and turn around
And it was already night-time.
Belem, we are very close
requesting further descend to flight level 4000 ft
254,
You are cleared for descend flight level 4000 ft
The controller clears the plane to descend further
to 4,000 ft
The captain expected he would be landing in Belem
in about 5 minutes
On the football pitch,
Brazil has taken the lead
Their goal of reaching the World Cup is in sight
But in the air
No visual lights, captain
the pilots of Varig 254
are no closer to finding the runway
Their actions indicate a slow realization
that they are not where they think they are
What is our fuel?
Now the question arises:
what are they going to do about it?
At Belem Airport,
the controller is growing concerned
Flight 254 should have landed 10 minutes ago
No visible lights, captain
They knew now there was a serious problem
When the flight didn't land
it was declared an emergency
On Flight 254, the situation is becoming critical
We need to land soon
or soon we are running out of fuel
I think we are close
When he flew over where he thought Belem should be
he didn't find it
It is very easy to find Belem
He didn't understand what was happening
Why don't we see if we pick up
a local radio-station from Belem?
The captain tries to home in
on a local radio signal
hoping it will help guide them toward the city
The automatic direction finders, or ADFs
are capable of tuning up
commercial AM radio stations
and that would have been very critical,
because this is a low population area
there is not a lot of geographic visual clues
We are talking about the Amazon
The do or die match is being broadcast
by radio-stations all across the country
Brazil leads 1-0 with 20 minutes to go
when suddenly controversy erupts on the field
One of the fans threw a flare,
that fell right next to the Chilean goalie
The goalie pretended that the flare hit him
and cut himself with a razor blade
His face was covered with blood
and the Chilean team abandoned the field
If Chili left the match for security reasons
they could be declared the winners of the match
Aboard Flight 254, the pilots have managed
to pick up a local station, broadcasting the match
Now we can follow the signal towards Belem
Turning right, heading 165
Passengers cannot understand
why the plane is turning yet again
We were getting extremely worried
The plane is going back and forth
The stars and the moon were on one side
and now they are on the other side
There is something wrong here,
what is going on?
The Captain is confident he is now on course
he spotted a landmark on his radar
There we go!
We are over the Amazon now
Belem is near the mouth of the Amazon
following the river
should lead the pilots to the city
but moments later, there is serious trouble
We've got a fuel warning
Flight 254 is running out of fuel
The pilots suddenly realize
they cannot make it to Belem
Do you want to put up flaps in case we lose power?
They will have to crash land
in the dense Amazon rainforest
Flaps to 2
We need to do a controlled descend
I'd better prepare the passengers.
Ladies and gentlemen, we have a malfunction
with our navigation instruments
and we will be making a forced landing
He said that there is going to be a forced landing
and that we should all take
our emergency positions
Bend your head down
and hold your legs together
and may God help us
those were his words
Panic begins to take hold in the cabin
Some people were praying
Others waited the bar and drank everything
Others were looking for the best spot
in case of a crash
Another passenger sat in the last row
He grabbed all the pillows
and completely covered himself with them
At 8:45 PM, Flight 254 runs out of fuel
The left engine is the first to die
We just lost an engine
Hang on
I am going to put her down
There goes the other one
With the 2nd engine gone
the 37 ton jet sinks closer and closer
to the ground below.
You have your eyes closed,
your life flashing before you
You ask God forgiveness
for all the wrong things you did in your life.
The inevitable impact is just seconds away
I just need to bring us down!
nice and slow
Then, what happened
was it started to touch the top of the trees
You are expecting the worst
He made the most difficult forced landing
in the history of aviation
meu deus no céu
When the plane stopped
I felt myself all over
to see if I had any cuts
or broken bones
And then I thought:
Am I in heaven?
Have I died and already in heaven?
Of the 54 passengers and crew
48 have survived
Many are badly hurt,
including first officer Zille
The First Officer Nilson Zille
was pierced on one side by a tree-branch
He was badly injured
He fractured his leg and his shoulder
Captain Garcez quickly takes control
of the situation
Captain Garcez didn't get hurt,
he didn't even have a scratch
At that point Garcez did everything
a captain must do
He helped those that he could help
He freed whoever he could,
those who were trapped in the metal debris
We have to get you
out of here, OKAY?
Can you hear me
Surviving the crash-landing feels like a miracle
to many of the passengers
But they now face a new threat to their survival
They are stranded in the vast Amazon rainforest
with no food, no water
and no guarantee that they will ever be found
The shattered fuselage of a 737
is now the only shelter
for survivors of Varig Flight 254
The plane's sudden disappearance
over the Amazon rainforest
has left Brazilian Aviation authorities
grasping for answers.
They turn to Colonel Ronaldo Jenkins
an air-crash investigator
with the Brazilian Air-force
They called me and said:
There is a commercial aircraft that was supposed
to arrive in Belem and it didn't arrive.
but no one knew exactly what happened to the plane
They left Maraba on time
but never got to Belem
This is our search area,
right here,
The first challenge is to look at the aircraft
I figured out the best way to reach it,
because initially, we weren't sure where it was.
Investigators interview the last person
to be in contact with Flight 254:
the Belem Air Traffic Controller
According to the controllers,
the communications were quite normal
Other than the strange fact,
that they weren't receiving a signal
from the ground based equipment,
the VOR beacon at Belem
He said he was close,
He asked me for descend
Belem Airport is not equipped with radar
The controller can only tell investigators
the pilot's last reported position
Because there was no radar,
the ATC relies on the proper navigation skills
of the pilots and their timely reports
With little else to go on,
rescuers concentrate the search
in a small radius around Belem.
They find no sign of Flight 254
You never start with a pre-conceived idea
that such and such happened
explode in mid-flight...
...lost an engine, non of this.
In other words: you go and search
of the aircraft that left one location
and is supposed to arrive in another
Investigators also comb through satellite data
hoping to find a signal
from the plane's emergency transmitter.
The distress beacon is designed to activate
after an accident
to help guide rescuers to the plane
The impact should have set off their locator
All we have to do,
is figure out which one is Flight 254
But the signal from those beacons is on the
same frequency as other emergency transmissions
making it hard to pin-point the plane
Every time you use this frequency,
or speak on this frequency
the satellite receives those messages
and so, it is a lot of work to identify which one
is the real position of the airplane
Meanwhile, somewhere in the Amazon rainforest
the survivors of Flight 254 are struggling
to stay alive
I was part of a group
and went out to search for water
There was a stream nearby,
we drank some water and we took some back
for the people who are in the plane
But Carlos Siqueira's efforts cannot save everyone
There were people there who were severely injured
and in horrific pain
and some of the passengers started dying
If help doesn't arrive soon,
more will die
The Captain had hoped, rescuers from Belem
would find the crash site within hours.
Now, a day later, he fears the plane's
emergency beacon isn't sending out a signal
It is working if I just can get it submerged
Some beacons are designed to activate only
when a plane is lost at sea
In the case of the Varig airplane,
it was the emergency locator transmitter only
transmitted when it was emerged in water
With precious water in short supply,
Garcez comes up with a creative solution
They urinated on it to submerge it
so, that it would be activated
I want to send a helicopter to go and confirm
the identity of this signal...
...here
You get anxious to find the plane quickly
because people have a better chance of survival
during the first 48 hours.
After that, survivors are more likely to die
After two nights in the jungle
the survivors realize
they cannot afford to wait to be rescued
People were weak, because we had water,
but no food.
Good luck!
A small group sets of in the jungle to find help
Hours later, they stumble on a farmhouse
Their terrifying ordeal will soon be over
They found survivors
It is a relief to realize
the scenario is not as tragic
and there is an urgent desire
to get to the location and start to work
Then, investigators get a shock
The crash-site is nowhere near Belem
It came down, right...
...here
The wreckage of Flight 254 is lying in the jungle,
nearly 700 miles away
I got heard they get way over there
We were really very surprised to learn
that the plane was in that location
Very far South, and very far West
of the position where it should have been
I wonder we can spot the beacon
It is no where near the destination
As search and rescue-team
scramble to the remote location
investigators are left with an urgent question
They were not supposed to be in that location,
so they got lost during the flight
Now, what caused them to get lost
continues to be a mystery
The Brazilian military reaches
the remote crash site of Varig 254
The survivors are air-lifted out
5 have died waiting for rescue,
another dies soon after.
There were some people who died,
not during the crash
but because they didn't get any medical aid
Many believe more would have died,
if not for the skill of Captain Garcez
Garcez was considered a great hero
by the Brazilian people
because he was the pilot,
he was able to land the plane in the dark
and saved 42 out of 54 passengers
I know this guy
He is a good pilot
Investigators are puzzled how a pilot
as accomplished as Garcez
could have flown so far off course
While I worked as an inspector for Varig
twice I oversaw Garcez
Twice!
and I could see
that he was a very disciplined pilot
and extremely professional
He knew the aircraft, knew the procedures
He definitely did things correctly
Our navigation instruments weren't working
It is very strange
I'd never encountered something like this before
The Captain claims
the plane's instruments malfunctioned
He was forced to navigate
by tuning in to a radio station
We had to improvise
News that the crew tuned in
to a commercial radio station
sparks media speculation that
the pilots became lost
because they were distracted by the match
You hear a lot of things
during an accident investigation
a lot of ungrounded speculation
I would call that
an incomplete and unsubstantiated accusation.
At the Amazon crash site,
there has been a major break-through:
the discovery of the plane's two flight-recorders
The FDR captures detailed information
about the plane's heading
Investigators hope it will reveal why Flight 254
was so badly off course
we were relying on the two recorders
Both pilots were alive
so we thought we were certain
to come to a conclusion
They also recover as many documents
from the cockpit as they can
The most important things at that moment
were navigation charts...
...all of them.
Manual, records, anything
that would provide support and guidance
for the pilots to fly the plane
Each fragile page is carefully photographed
to prevent further damage
Meanwhile, investigators use the heading data
to reconstruct the path of the plane
They took of due West,
heading 270
The Flight Data Recorder was fundamental,
it provided us with the track of the airplane
the positions, the times...
...where the airplane flew
But the flight data paints a confusing picture
Instead of flying North to Belem,
the plane took of West
and flew in the wrong direction,
throughout the flight
They were flying
the wrong way for the entire flight
This became a central focus of the investigation
to know why the aircraft was so far off course
A broken navigation system
could explain the mistake
but when the investigators try to get
more information from the crew
they hit an unexpected roadblock
The pilots union
flies Garcez and Zille to Rio de Janeiro
denying investigators access to them
for several days
The Union believed the investigators
would hold the pilots responsible for the crash
For now, the only words from the pilots
that investigators can hear
are those, captured on the CVR
Let's hear it!
We just lost one engine
do bring us down
nice and slow
It is the hardest part of the job
for any air crash investigator
Hearing the fear in a pilot's voice
We just lost the other one!
and listening, as a fatal tragedy unfolds
Rewind it please,
all the way to the beginning
Investigators hope, the 30 minute recording
can tell them why the pilots
flew in the wrong direction
But they are out of luck
We are over the Amazon now
By the time the recording starts,
the pilots are already badly lost
Whatever led them off course,
happened earlier in the flight
CVRs traditionally have been
the last 30 minutes of flight
Only in recent years has that recording length
been extended to 2 hours
The problem started
during the first moments of the flight
We didn't have a recording,
because of the time-limitations of the CVR
Investigators are desperate for more information
They study the navigational instruments,
recovered from the cockpit
we sat out to make a complete analyses
of the entire navigation system of the aircraft
They know the captain reported
a malfunction in the navigation system
that puts his plane hundreds of miles off course
The need to figure out what could have caused
such a malfunction
if they don't, the lives of passengers
around the globe could be in danger.
We were very concerned,
because there were at least 30 other
aircraft of the same model flying in Brazil
If it happened to one,
it can happen to others
The pressure on investigators is huge.
Investigators look into the possibility
that the navigation system on
Varig Flight 254 malfunctioned
and led the crew off course
In a situation where there is this much confusion
about where they are
one of the questions that come up is
what systems have may have malfunctioned?
They suspect the plane's cargo may hold the key
The 737 has a magnetic sensor in the tail
that acts as the plane's compass
It tracks which direction the plane is flying
and feeds that information
to the cockpit instruments
If something in Flight 254's cargo
was giving off a strong magnetic field
it might have confused the sensor
we studied every aspect of the cargo
even things that might have
been on the shipping pallets
that might have influenced
something in this regard
They also test
every component of the navigation system
and check for any sign of failure
but they find nothing in the cargo
that could affect the compass
and the instruments are working perfectly.
we verified that there was nothing that
might have caused the electromagnetic interference
Nothing that could have changed the heading...
...or influence the change of course
Investigators catch a break
Flight 254's flight-plan
has been recovered from the cockpit
Airlines provide flight-plans to every crew
It contains critical details
about the route they should fly
including the heading they are meant to take
Let us see what this will tell us
The airline provides a detailed flight-plan
in a computer printout to the flight-crews
This provides a series of waypoints
that they are to look for to fly the ground-track
But what if the airline
gave the pilots a faulty flight-plan
One that send them in the wrong direction?
This could be the lead they have been waiting for
I think I know what they did wrong
A close look at Varig 254's flight-plan
provides a revelation
In this particular case with the Varig Flight
Very unusually, their computer flight-plan system
has 4 digits
This is very, very unusual
as they almost always have only 3
The numbers 0270 was intended to mean
27.0 degrees
When we noticed that, it gave us the idea
that instead of entering 027
which was the heading to Belem
he had entered 270
He was supposed to fly North,
heading 027
The captain read it as 270 degrees,
or due West
So, instead of flying North-East
they went West, instead
he entered the wrong heading
He set the airplane up to depart West
270 degrees or due West on the compass
is more than 240° passed the Northerly heading
of 27° they were given
The moment of truth arrives
when they call Captain Garcez back in
to give his side if the story
I'll try to help you,
but I think I told you everything you know already
We told Garcez:
Look, we have the on-board charts
We have the tapes and all of the documents...
...verified by us
What is the truth
(O que é a verdade)
At first the captain is reluctant to admit
he made a mistake
We said:
Garcez, tell us the truth
You didn't have a problem
with the navigation instruments, did you?
Under intense questioning, Garcez finally admit
he misread the flight-plan
Look, it was an honest mistake
From that moment on,
the cause or the basic framework of the accident
was determined
Investigators learn the airline began
printing their flight-plans this new way,
while the captain was on vacation.
It is easy to see
how you get confused
Varig had bought some more sophisticated planes
which had instruments that accepted decimal places
But that wouldn't mean anything on this flight
since the Boeing 737-200
didn't have decimal places
But there is another question
The first officer must also enter the heading
from the flight-plan
So, Nilson,
do you think Chili has a chance tonight?
Why did he make exactly the same mistake
as the Captain
Aviation psychologist Kathleen Mosier
has an answer
The copilot,
probably after many experiences with captains
who had always done it right
and never have to double-check
just entered what the captain had put in
and assumed that was the right thing
So, in this case, your safe-guarding is gone,
because the copilot is not cross checking
He could have caught this mistake
before they took off
Once you take of,
the automation does what you told it to do
Varig 254 takes off due West,
instead of North...
...straight into the setting sun
It is an incomprehensible error
Do you not realize
that you are flying into the sun?
That should have been a big cue
They must have been very confident
that they had done the right thing
The two pilots disagree about
how things went wrong
We need to land soon
or we are going to run out of fuel
I think we are close
The first officer was protecting himself,
suggesting that he had done everything right
and Garcez was at fault
The original navigation mistake
was that of the captain
The failure to independently verify
was a mistake on the part of the first officer
What is disheartening here
is that both pilots went along with it
It is now all too clear that Flight 254
was flying in the wrong direction
from the moment it took off
A mistake even some passengers noticed
Well, we thought the person in charge here
is the captain
At least three of the passengers
warned the flight attendance
that the plane was flying
in the wrong direction
but the flight attendance thought:
Well , the Captain knows more about this
and they didn't reach Garcez to warn him
that he was flying in the wrong direction
We thought that, up in the sky,
the captain is in charge, so
But it is what the captain does next:
to turn his error into a catastrophe
The crew of Varig 254 makes
a critical error in judgement
We decided to tune in to a radio station
Instead of radioing for help,
they try to get back on course
without admitting their mistake
His pride prevented him
from saying to his colleague:
Help me, I am in trouble
That would have been a better approach.
Their attempt to use commercial radio-station
to find the airport...
...doesn't help.
They wrongly assumed
the signal is coming from Belem
they follow it away from their destination
When you tune into a commercial radio broadcast
it is possible to receive content,
originated from different locations
Garcez, can you believe this?
They still haven't restarted the match
You need to verify that it is in fact that station
that it identifies its call letters
and that you have that validation
Can you believe those guys?
Though there is no hard evidence,
some continue to believe
the pilots were distracted by the football match.
People say:
He was listening to the Brazil-Chili match
and that is why he didn't notice his mistake.
But investigators believe
there may be a psychological explanation
A quirk of human nature that can trap
even the best trained pilots
There we go,
We are over the Amazon now
The captain spotted a river
A river that he thought was part of the Amazon,
North of Belem
you decide on your initial judgement
and you think that it is right
and so, you look around for things
that support your position
The crew was looking for signs
that they were close to Belem
He decided to follow that river South,
to get to Belem
But the river they saw was not the Amazon
It was the Xingu,
a river more than 600 miles South-West of Belem
they were so confused for so long
Investigators conclude the crew was in the grip
of what is know as confirmation bias:
the tendency to favour information
that confirms something we already believe.
I think we are close
Confirmation bias is one of
the common decision making biasses
that people are subject to
the thing is that you don't often recognize
that is what you are doing
When I saw the river I was sure
I was sure we were close to Belem
This case show you
anybody can fall into decision traps
even experts have to always be on guard
In 3+ decades of doing accident investigation
this is one of the most unusual accidents
I have ever read or am aware of
The accident-report faults
both pilots for the disaster
As the details of the flights were discovered,
the terrible mistake that he made
the captain went from hero to villain
They were both convicted for their negligence
and sentenced to community service
The report also criticizes the Belem controller,
for not raising an alarm sooner
The controller at Belem tower
was very worried about the football match
between Brazil and Chili
He had one ear on the broadcast of the match
and the other paying attention to the flight
254, you are cleared for descend
He should have realized
there was a problem
when the plane could only
contact the tower on HF radio
A major clue that the plane is probably far away
Everybody makes mistakes,
errors are not unavoidable
The way that you deal with this
is that you be aware of the threat
You try and trap errors,
if they occur, and fix them
I think it was the failure
of these two pilots
to maintain the highest standards
of professional airmen-ship
I think, in that point,
they did not meet the necessary mark.
After the crash of Varig 254
the airline changes their flight-plans
So the decimal place is clearly marked
They also improve pilot training
Brazil's national radar system is modernized
and expanded to cover the entire country
making it less likely that a plane will go missing
Brazil never even made it
to the quarter finals of the 1990 World Cup
which was won by West Germany
The scandal of the Brazil-Chili match
faded over time
But the legacy of Flight 254 endures
This is one of those cases we are looking and
understanding what this crew did
can serve as an
absolute bright example
to help crews in the future
not make these same mistakes
Narrator
Jonathan Aris
Subtitles
Rein Croonen