Original subtitles

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