Introduction: the Setting
This accident could have been avoided. Twelve families did not have to collapse. None of the survivors had to experience such trauma.
VARIG was one of the leading airlines founded in Brazil and it played a vital role in its one and only international flight before 2008. However, one of the most bizarre incidents in the history of civil aviation happened to this airline in the 1980s: a plane flew in the opposite direction and lost its way.
On September 9, 1989, VARIG flight 254 was designated to depart from Sāo Paola and arrive at the north of Brazil, Belém, over six stopovers: Uberaba, Uberlândia, Goiânia, Brasília, Imperatriz, and Marabá, respectively. But, instead of landing in Belem, the plane crashed in a jungle northwest of Rio de Janeiro – located to the south of Marabá, the last stopover of this flight.
The fundamental reason that led to this flight crash was the Captain, Cézar Augusto Padula Garcez, and the co-pilot, Nilson de Souza Zille, both put the wrong heading prior to departure. The heading is the degree which the plane heads to during the flight. You may be asking, “how is that even possible?”With such a skilled copilot and knowledgeable captain who served in the air force with over 7,000 hours of flight experience, how could they make such a mistake without realizing it? Well, this article will walk you through how many times this mistake could have been fixed and how many different ways this incident could have been avoided.
Captain Garcez
How did it happen? What did they miss during the flight?
When Captain Garcez first received the heading (the indicator of which the plane will go) from the flight plan, the number read 0270. While it was printed in four digits with a decimal point implied, meaning 27.0°, Garcez interpreted it as 270°. Garcez was on vacation when the Brazilian airline decided to utilize an extra significant figure to enhance its precision. No one informed him and there was no manual – this was the first fatal mistake. While the system was designed for both captain and copilot to enter the heading, copilot Zille simply looked over Garcez's input and, without hesitation, aligned his measurement to 270 degrees as well.
Along the way, there were also many signs that the crew missed that could have stopped this tragedy. Firstly, the flight from Marabá to Belém pointed straight north, but they initially headed to the west, which faced the sun and headed towards the sunset directly. In theory, a crew with such extensive aviation experience and profound background in geography could have noticed it very easily. The truth was, they did not.
After, they lost connection with Belém control tower since they were supposed to be in contact throughout after they had left Marabá, but Garcez thought it must have been some temporary technical difficulty that the airplane was experiencing and he believed it would come back very shortly. Meanwhile, even though the frequency of radio for Belém and the city near Xingu river were the same, the code sent to flight 254 was completely different. Nonetheless, out of negligence, neither Garcez nor Zille confirmed with Belém.
Furthermore, the Point Merge System (abbreviated as PMS) then reported that they were indeed arriving in Belém very soon. Little did they realize, the PMS didn’t account for its direction but only its mileage and fuel gauge. This false indicator let off the weight on Garcez’s mind and finally ensured that their route was back on track.
After almost two hours of flight that was originally planned to be 48 minutes, the crew still was not reflecting on their problem, instead, they blindly looked for the never-reaching airport. At this time, they might have realized they were “somewhat” lost and even though they had contact with the outside world through radios, they did not seek any help. Perhaps, if they had asked for help, none of what happened would have occurred.
At last, Garcez and Zille came across a river – a river that they thought to be the Amazon river, but, in fact, was the Xingu river. Knowing that Amazon runs north-south when Xingu runs west-east, it was ridiculous that the crew was not worried. However, they carelessly believed that Belém was so close within their sights. Garcez even continued south and reported their findings to the Belém air traffic control tower, which was connected to the wrong department in the tower due to an incorrect range of radio frequency.
Map of Brazil
The Final Arrival and Aftermath
By the time flight 254 ran out of fuel, it reached the southernmost end of Xingu river, Garcez finally recognized the plane might have been lost over the course of three hours. He noticed that he didn’t see any signature architecture and landmarks of Belém and knew something was wrong. At that point, the impact of his mistake was irreversible, which forced them to “belly land” in the middle of a jungle that the radio could not reach. Of course, the rescue then took an excessive amount of time because the traffic tower thought they landed somewhere near the outskirt of Belém, almost 500 miles away from Xingu river.
Not only was the crew not fully aware of their negligence, but the Belém control tower was also supposed to report promptly once flight 254 delayed their arrival time. Moreover, months after this incident happened, the International Federation of Air Line Pilots' Associations (IFALPA) sent the flight plan for Flight 254 to 21 pilots from ten major international airlines around the world to test its validity. Surprisingly, it turned out that 15 out of 21 personnel made the same mistake as Garcez. To prevent any accident similar to reoccur, airlines added the decimal points directly to the number to reduce misunderstandings and conditions (in the case of 270°, it would be written as 270.0 and 27° would be written as 27.0).
It was unfortunate that all changes came with tragedies; but if no progression is made even afterward, the accident would have been truly unappreciative. While this occurrence sounds absurd, it happened in reality. We will all learn from the past and remember that each of our actions impacts someone or something. Even though it may seem minor, this tragedy would have been avoided if any of the glaring mistakes were corrected over the three hours, sadly none were noticed.
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