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Varig Flight 254

Varig Flight 254 was a scheduled domestic passenger flight operated by the Brazilian airline Varig that crashed in the Amazon rainforest on September 3, 1989, after the crew entered an incorrect navigation heading, leading to fuel exhaustion and a forced landing approximately 600 kilometers off course, resulting in 12 fatalities out of 54 people on board.^[1]^[2] The flight originated in São Paulo (GRU) and was en route to Belém (BEL), with intermediate stops including Brasília, Imperatriz, and Marabá; the accident occurred during the leg from Marabá Airport (MAB) to Belém Val de Cans International Airport (BEL), departing Marabá at approximately 17:30 local time.^[1]^[3] The aircraft involved was a Boeing 737-241 Advanced, registration PP-VMK (manufacturer serial number 21006), which had been in service since 1974 and was powered by two Pratt & Whitney JT8D-17A turbofan engines; it carried 48 passengers and 6 crew members, including Captain Cezar Augusto Garcez (age 32, with over 4,000 flight hours) and First Officer Nilson de Miranda Zille (age 29, with about 2,500 flight hours).^[1]^[3] Shortly after takeoff from Marabá, the crew misread the initial outbound heading on the computerized flight plan sheet, which listed "0270" (indicating 027.0°) but was interpreted as 270°; due to the three-digit input limitation of the aircraft's flight director system, they programmed 270° instead of 027°, causing the Boeing 737 to turn westward into the remote Amazon jungle rather than northeast toward Belém.^[1]^[3] The error went unnoticed for over three hours as the plane flew off course without effective cross-checking of navigation aids or radio fixes, consuming fuel until both engines flamed out around 20:45 local time near São José do Xingu in Mato Grosso state; the crew attempted a glide and executed a controlled crash-landing in a small clearing, where the aircraft broke apart and caught fire, killing 8 people immediately and injuring many others.^[1]^[3] Four more succumbed to injuries and exposure in the ensuing days before rescue.^[1] The 42 survivors faced harsh jungle conditions, including heavy rain, insects, and limited food and water, while using the aircraft's radio to broadcast a mayday call on September 5; Brazilian Army helicopters located the site that day, initiating a massive rescue operation that evacuated all remaining survivors by September 6, though some suffered long-term health effects from dehydration and trauma.^[3]^[2] The wreckage was deemed destroyed beyond repair, and the incident highlighted vulnerabilities in flight planning documentation and crew resource management in remote areas. The official investigation by Brazil's Centro de Investigação e Prevenção de Acidentes Aeronáuticos (CENIPA) determined the primary cause as human error in interpreting and programming the navigation data, exacerbated by inadequate verification procedures and the ambiguous formatting of the flight plan (lacking clear decimal point emphasis); no mechanical failures were found, though contributing factors included fatigue from a long duty day and insufficient training on the specific flight management system.^[1]^[3] CENIPA's final report led to recommendations for standardized flight plan formats with explicit decimal notations, enhanced crew training on navigation cross-checks, and improved survival equipment for jungle operations, influencing global aviation safety protocols for visual flight rules in low-visibility regions.^[1]^[3]

Background

Varig Operations

Varig, officially known as Viação Aérea Rio-Grandense, was founded on May 7, 1927, in Porto Alegre, Brazil, by German immigrant and aviator Otto Ernst Meyer, who obtained a license to operate the country's first registered commercial aircraft, a nine-passenger Dornier Wal flying boat named Atlântico. Initially focused on mail and passenger services in southern Brazil, the airline expanded under the post-World War II leadership of Ruben Berta, who introduced employee ownership through the Berta Foundation in 1945, eventually controlling about 80% of the company's stock by the late 20th century. By the 1960s, Varig had become Brazil's flagship carrier and largest airline, operating an extensive domestic network alongside international routes to Europe, North America, and South America, with a fleet that grew to include jet aircraft like the Boeing 707 in the 1960s and Boeing 747s by the 1970s. In the late 1980s, Varig emphasized regional services to connect underserved areas, particularly through subsidiaries like Rio-Sul, established in 1976 as a dedicated regional operator. Rio-Sul began with a fleet of two Embraer EMB-110 Bandeirante twin-turboprop aircraft, designed for short-haul operations carrying 15 to 21 passengers on unpaved or short runways, which proved suitable for Brazil's vast interior. These turboprops enabled expansion into regional routes, including those in the Amazon basin, where Varig's network supported economic development by linking remote communities to major hubs like Manaus. Operations in this region involved navigating challenges such as short, unprepared airstrips and unpredictable weather patterns, including heavy rains and fog that could limit visibility and require flexible routing. By 1989, Varig's operational standards adhered to Brazilian civil aviation regulations under the Departamento de Aviação Civil (DAC), emphasizing safety through rigorous maintenance equivalent to U.S. Federal Aviation Administration (FAA) practices and crew proficiency checks. Pilot training programs, conducted at Varig's facilities, included instruction on transitions between visual flight rules (VFR) and instrument flight rules (IFR), essential for regional flights where weather could shift rapidly from clear skies to instrument conditions. In underserved Amazonian areas, crews relied on manual navigation aids like VHF omnidirectional range (VOR) stations and dead reckoning, given the limited ground-based infrastructure compared to coastal routes. These practices supported Varig's role in domestic connectivity, with subsidiaries operating dozens of daily flights to maintain service reliability amid environmental and logistical hurdles.

Flight Details

Varig Flight 254 was a scheduled domestic passenger service operated by the Brazilian airline Varig on September 3, 1989, originating from Congonhas Airport in São Paulo and destined for Val de Cans International Airport in Belém, with multiple intermediate stops along the route, including a key layover in Marabá. This multi-leg itinerary was part of Varig's routine regional network connecting major urban centers to northern Brazil, emphasizing efficient short-haul connectivity across diverse terrain. On the critical segment from Marabá to Belém, the flight manifest recorded 48 passengers and 6 crew members aboard, resulting in a notably light load that was characteristic of such interior hops where demand often varied due to the remote destinations. The passenger composition included a mix of locals and travelers heading to the Amazon region, with no significant cargo noted beyond standard provisions. This underutilization reflected the operational realities of servicing less-populated routes in Brazil's vast interior. Pre-flight preparations in Marabá included standard meteorological briefings, which reported clear skies and calm conditions at the airport, facilitating an uneventful departure at approximately 17:25 local time. However, briefings also highlighted the potential for isolated thunderstorms deeper in the Amazon basin, a common variability in the region's tropical climate that pilots were advised to monitor en route.

Crew and Aircraft

The flight crew consisted of Captain Cézar Augusto Padula Garcez and First Officer Nilson de Souza Zille. Captain Garcez, aged 32, possessed nearly 7,000 total flight hours, including extensive experience on the Boeing 737, while First Officer Zille, aged 29, had 1,245 total flight hours, also with notable time on the type; however, the investigation noted discrepancies in the interpretation of their logbooks regarding specific experience levels on similar routes. The cabin crew included four flight attendants, led by a chief attendant, who were responsible for delivering pre-flight safety briefings, monitoring passenger comfort, and ensuring compliance with emergency procedures during the multi-stop journey. The aircraft was a Boeing 737-241 Advanced, registered as PP-VMK, manufactured in 1975 and delivered new to Varig, with a total of 33,373 flight hours at the time of the incident. It had undergone routine maintenance inspections in accordance with Varig's program, including a recent C-check, and no defects or irregularities were recorded in its technical logbook prior to departure. Equipped with standard VOR/DME and NDB navigation aids typical for 1980s-era Boeing 737s, the plane lacked modern GPS or inertial reference systems. For the final leg from Marabá to Belém, it carried 2,400 liters of Jet A-1 fuel, calculated to cover the approximately 320-nautical-mile route plus required reserves.

The Accident

Departure and En Route

Varig Flight 254, operating the final leg of its multi-stop domestic route from São Paulo to Belém, departed Marabá Airport (SBMA) at 17:25 local time on September 3, 1989.^[1] The Boeing 737-200 advanced, registered PP-VMK, took off without issues and climbed steadily to its cruising altitude of Flight Level 290, equivalent to approximately 29,000 feet.^[1]^[4] Air traffic control from Belém Area Control Center provided standard clearance for the VOR-based navigation route, directing the aircraft to proceed on the 027-degree radial from the Marabá VOR beacon toward the destination.^[1]^[4] Routine position reports and acknowledgments were exchanged between the crew and ATC during the initial climb and early cruise, confirming adherence to the assigned heading and altitude with no deviations noted at that stage.^[1] En route, the flight maintained normal operations, with the crew performing standard checks on systems, navigation instruments, and fuel quantities as per Varig's procedures.^[4] The aircraft's performance showed no immediate anomalies, and the pilots, who had successfully completed the prior legs of the journey, continued monitoring the progress toward Belém, approximately 187 nautical miles (346 kilometers) northwest.^[1]^[4] During the flight leg from Marabá to Belém, the pilots encountered a critical navigation error stemming from a misinterpretation of the flight plan's outbound heading. The computerized flight plan listed the heading as "0270", which was intended to indicate 027.0° but was read by the crew as 27.0°; due to the three-digit input limitation of the aircraft's flight director system, they programmed 270° instead of 027°, directing the Boeing 737-241 onto a significantly altered course.^[4]^[5] Unaware of the deviation, the aircraft proceeded westward along the erroneous heading of 270°, veering deep into the uninhabited Amazon rainforest. Over the next three hours and forty minutes, the flight covered roughly 600 kilometers off the planned route, passing beyond the range of expected radio navigation aids without the crew recognizing the anomaly. As fuel reserves dwindled, the pilots attempted to locate suitable landmarks or signals but found none in the remote terrain.^[4]^[1] With both engines failing due to fuel exhaustion, the crew initiated a forced landing at approximately 20:45 local time in a densely vegetated area near São José do Xingu, Mato Grosso state. The aircraft struck trees and rough ground, breaking into multiple sections upon impact and skidding through the undergrowth.^[4]^[1]

Rescue and Survival

Initial Survival Efforts

Following the forced landing in the remote Amazon jungle on September 3, 1989, 46 of the 54 people on board Varig Flight 254 survived the initial impact, including all six crew members. Captain Cézar Augusto Padula Garcez, despite his own injuries, immediately took charge of the survivors, organizing efforts to assess injuries and move the most severely hurt away from the wreckage to reduce risks from potential fire or further collapse.^[6]^[3] The survivors sought shelter using sections of the Boeing 737's fuselage and scattered debris, huddling together to protect against the jungle environment while tending to wounds with limited onboard first-aid supplies. Injuries ranged from cuts and bruises to more serious cases requiring basic immobilization, though medical resources were scarce in the isolated location. To conserve hydration, the group rationed available water from the aircraft's galley supplies, later supplementing it by locating a nearby stream after initial exploration.^[3] Communication attempts began promptly, with the captain activating the emergency locator transmitter approximately two hours post-crash by improvising coolant using melted ice from the galley and urine, though radio signals failed to penetrate the dense terrain. The survivors also prepared materials for signal fires in hopes of attracting attention from potential overflights, prioritizing these measures while conserving energy amid the growing threat of dehydration and exposure.^[3]

Search Operations

The flight was reported overdue around 19:40 local time on September 3, 1989, after failing to arrive in Belém as scheduled and losing radio contact en route from Marabá. Initial search efforts began that evening, coordinated by Varig Airlines and Brazil's Infraero rescue teams, focusing on the Amazon jungle region along the expected flight path. The Brazilian Air Force assumed primary responsibility the following day, September 4, initiating radar monitoring and low-level reconnaissance flights to cover potential crash sites.^[7]^[8] Search operations encountered major obstacles due to the crash site's remote position deep in the Amazon rainforest, where dense vegetation and limited visibility hindered aerial detection. The emergency locator transmitter's signal was picked up but difficult to triangulate precisely amid the terrain and weather conditions, leading to an expanded operational area spanning hundreds of thousands of square kilometers. Resources included fixed-wing aircraft for broad sweeps and helicopters for closer inspection, though nighttime and haze further delayed progress, with searches temporarily suspended overnight on September 4.^[8]^[1] The wreckage was discovered on September 5, approximately 44 hours after the forced landing, when Brazilian Air Force aircraft confirmed the location near São José do Xingu in Mato Grosso state. This breakthrough was facilitated in part by four survivors, led by passenger Alfonso Saraiva, who trekked approximately 2-3 hours through the jungle to reach the Curunaré farm and subsequently a radio-equipped ranch, alerting authorities to the precise area around 12:30 local time. At 16:27, an Air Force aircraft dropped food, water, and medical supplies to the site. Rescue execution began immediately thereafter; on September 6, Air Force helicopters commenced airlifting the 41 survivors from the inaccessible site, winching them aboard due to the inability to land amid the thick canopy. All survivors were first transported to a nearby ranch for initial assessment before medical evacuations to hospitals in Belém were completed by September 7.^[1]^[6]^[9]

Investigation and Causes

Inquiry Process

The official investigation into the crash of Varig Flight 254 was led by Brazil's Aeronautical Accidents Investigation and Prevention Center (CENIPA), the national authority responsible for analyzing aviation accidents.^[1] Following the accident on September 3, 1989, search efforts located the wreckage approximately 44 hours later in a remote area of the Amazon jungle near São José do Xingu. CENIPA investigators conducted an on-site examination of the site and aircraft remains from September 8 to 10, focusing on recovering key components for further analysis. The wreckage recovery was challenging due to the dense terrain and weather conditions, but it allowed for detailed assessment of the aircraft's structural integrity and systems.^[1]^[4] Key methods employed included the recovery and analysis of the aircraft's flight data recorder and cockpit voice recorder, though data from the older Boeing 737-200 model was limited in scope compared to modern systems. Investigators also conducted extensive interviews with the surviving crew members and passengers to reconstruct the flight's events and decision-making processes. Additionally, witness statements from air traffic control personnel and local residents were gathered to corroborate the timeline. Meteorological data from relevant weather stations was incorporated to evaluate environmental factors during the flight.^[1]^[4] The full investigation spanned about 1 year and 7 months, culminating in the release of CENIPA's final report on 23 April 1991, which detailed the evidence collected and investigative procedures.^[1]

Root Causes and Contributing Factors

The primary cause of the Varig Flight 254 accident was pilot error, specifically the captain's misinterpretation of the flight plan coordinates, resulting in the entry of a heading of 270° into the aircraft's flight management system instead of the correct 027°. This error directed the Boeing 737-200 westward into the Amazon rainforest rather than northeast toward Belém, leading to fuel exhaustion and a forced landing approximately 690 kilometers off course. The flight plan, prepared by Varig, listed the outbound radial from Marabá's VOR station as "0270," which the crew erroneously read as 270° due to an implied but unclear decimal point placement—a format more suitable for aircraft with inertial navigation systems (INS) like the DC-10, not the 737's basic VOR/NDB setup.^[1]^[4]^[3] Contributing factors included the ambiguous presentation of navigation data in the flight documentation, which lacked explicit decimal indicators or route identifiers, fostering the misreading. The first officer failed to independently verify the heading, instead copying the captain's input without cross-checking against the flight plan or external aids, highlighting deficiencies in cockpit resource management. Additionally, the crew's schedule that day involved five flight legs with minimal rest between them, contributing to fatigue and reduced vigilance; the captain, in particular, displayed signs of complacency after a demanding sequence of short-haul operations.^[1]^[4]^[3] Systemic issues exacerbated the incident, notably the absence of redundant navigation systems on the aircraft, which relied solely on VHF omnidirectional range (VOR) and non-directional beacons (NDB) without INS or GPS for backup verification. Inadequate training at Varig emphasized INS procedures over VOR/NDB interpretation, leaving pilots underprepared for error detection in remote sectors. Furthermore, air traffic control (ATC) oversight was limited in the Amazon region, with no radar coverage at Belém and intermittent radio communications, preventing timely course corrections despite the crew's eventual queries about position. The investigation noted that these organizational shortcomings allowed the initial error to persist undetected for over three hours.^[1]^[4]^[3]

Aftermath and Legacy

Casualties and Memorials

The crash of Varig Flight 254 resulted in 13 fatalities among the 54 passengers and crew on board.^[1]^[2] Eight individuals died upon impact from injuries sustained during the belly landing in the Amazon jungle, while five more succumbed to their injuries compounded by dehydration, exposure, and lack of medical aid over the subsequent days before rescue operations located the site.^[10] The initial deaths were due to severe impact injuries, whereas the post-crash fatalities involved complications from trauma and environmental factors in the remote terrain.^[2] Of the 41 survivors, many suffered serious injuries including fractures, lacerations, and internal trauma, necessitating extended hospital treatment and rehabilitation upon evacuation.^[11] Long-term recoveries varied, with some passengers reporting ongoing physical limitations and psychological effects from the ordeal.^[6] Survivor accounts emphasized the captain's role in calming the group and rationing limited supplies, as well as the contributions of a teenage passenger who assisted in signaling for help and tending to the wounded.^[9]

Safety Improvements and Dramatizations

The accident of Varig Flight 254 prompted several regulatory and procedural changes in Brazilian aviation to address navigation errors and improve safety protocols. The Brazilian Center for Aviation Accident Investigation and Prevention (CENIPA) investigation emphasized the need for clearer documentation and verification processes, leading to standardized flight plan formats across airlines to prevent misinterpretation of headings, such as the confusion between three-digit and four-digit notations.^[3] In response, Varig revised its flight plan layout to explicitly include decimal points and four-digit entries, eliminating the latent ambiguity that contributed to the crew's error.^[5] These reforms extended to enhanced pilot training requirements, focusing on coordinate interpretation and cross-verification procedures during flight planning. Brazilian aviation authorities mandated recurrent training modules on navigation systems and error detection, drawing directly from the incident's lessons to mitigate risks in regional operations over remote areas.^[3] By the early 1990s, regulations required regional aircraft to retrofit advanced navigation systems, including early GPS capabilities, to provide redundant positioning data beyond traditional VOR and NDB aids, significantly reducing the potential for controlled flight into terrain (CFIT) in Brazil's challenging airspace.^[1] On the industry level, Varig accelerated the adoption of digital navigation aids, such as Omega long-range systems, across its fleet to enhance accuracy in low-visibility or signal-poor environments like the Amazon region. This shift contributed to a measurable decline in CFIT incidents in Brazilian domestic aviation, with post-1990 data showing improved navigation reliability and fewer deviation-related accidents.^[5] The incident has been dramatized in various media to underscore aviation safety themes. It featured prominently in the television series Air Crash Investigation (also known as Mayday: Air Disaster), in the episode "Vanishing Act" from Season 14, Episode 3, aired in 2015, which reconstructs the navigation failure and survival ordeal.^[12] Brazilian media has covered the event through documentaries and interviews, including segments on national broadcaster Rede Globo's Fantástico program in the late 1980s and early 1990s, as well as later video essays by aviation historians exploring the crew's perspectives. Books such as Varig: The Rise and Fall of Brazil's National Airline by Barry Lloyd (2023) reference the crash as a pivotal moment in the carrier's safety evolution.^[13]

References

[1]
https://aviation-safety.net/database/record.php?id=19890903-0
[2]
Death count rises to 13 in Brazil plane crash - UPI Archives
Sep 6, 1989 · Varig Airlines said 13 people were killed and five seriously injured either in the crash or from the subsequent lack of medical attention while ...
[3]
35 Years On: How a Navigation Mistake Sent VARIG Flight 254 Into ...
Sep 3, 2024 · The investigation following the accident revealed that the primary cause of the disaster was the captain's navigation error, compounded by the ...
[4]
VARIG S.A. (Viação Aérea Rio-Grandense) -- Company History
VARIG was founded by a German immigrant, Otto Meyer, when he obtained a license to operate Brazil's first registered commercial aircraft, a nine-passenger ...
[5]
The Rise And Fall Of Varig - Latin America's Largest 747 Operator
Sep 12, 2023 · Varig was founded in 1927 by the German aviator Otto Ernst Meyer-Labastille. It was one of the oldest carriers in Latin America, along with ...Missing: growth flagship
[6]
Varig Rise and Fall - Key Aero
Sep 17, 2020 · Viação Aérea Rio-Grandense (Rio Grandean Airways) or Varig was established in 1927 after Meyer struck a deal with German trade company and ...Missing: flagship | Show results with:flagship
[7]
Rio Sul e Nordeste - ::: | VARIG AIRLINES | :::
The first aircraft was Embraer EMB-110. Nordeste undergone a major transformation in 1995, when it was bought by Rio Sul, VARIG's subsidiary. The company's ...Missing: Bandeirante | Show results with:Bandeirante
[8]
Embraer EMB-110 "Bandeirante"
The first EMB110 Bandeirante flew for the first time in August 1972 and entered commercial operation in April 1973 by Transbrasil. But it main order was from ...
[9]
[PDF] ANALYSIS OF THE REGIONAL AIR PASSENGER TRANSPORT ...
This paper focuses on the regional aspects of airline passenger traffic in Brazil, based on a review of the literature and interviews with some key government ...
[10]
[PDF] final report a-00x/cenipa/2008 - Flight Safety Detectives
This Final Report refers to the accident of 29 September 2006, typified as MID-AIR ... SIC and PIC, same magnetic headings and same flight time of the accident ...
[11]
[PDF] Controlled Flight Into Terrain Education and Training Aid - SKYbrary
Preventing CFIT accidents is the major goal of this training aid. The training aid includes a document (two volumes) and a video.
[12]
Decimal Point Disaster: Varig 254 - YESTERDAY'S AIRLINES
Mar 21, 2016 · A total of 13 passengers were killed and 34 passengers and crew were injured. Photo from the crash site of PP-VMK. Photo from the crash site ...
[13]
THE PLANE THAT GOT SWALLOWED BY THE AMAZON - YouTube
Jun 5, 2024 · On the evening of September 3rd, 1989, Varig Flight 254, a Boeing 737 ... The aircraft was in perfect working order, the weather was clear,
[14]
https://latinamericanpost.com/americas/lost-over-the-amazon-the-tragic-journey-of-varig-flight-254
[15]
None
Nothing is retrieved...<|control11|><|separator|>
[16]
Varig Flight 254: Downed by a decimal point - AviationKnowledge
Sep 6, 2011 · Varig flight 254 was a Boeing 737-200 which made a forced landing in the Amazon jungle after running out of fuel on 3 September 1989, 600 miles off course.
[17]
Survivors Airlifted From Brazil Crash Site; Pilot, Teen-Ager Hailed
Sep 7, 1989 · Survivors of the crash credited the plane's captain and a teen-ager for helping save their lives. They also described scenes of panic and ...
[18]
Captain Refused to Acknowledge He Was Lost - Preaching Today
Captain Garcez made a mistake, lied about a power failure, dismissed the first officer's explanation, and refused to ask for help, leading to a crash landing.Missing: experience | Show results with:experience
[19]
Jet With 54 on Board Missing in Brazil : Disappears Over Amazon
Sep 5, 1989 · Ronaldo Borges said the search for the Varig Boeing 737-200, which disappeared Sunday, had been suspended until early today. Last Leg of Flight.
[20]
After Trek From Brazil Crash, Survivor Says 46 of 54 Live
Sep 6, 1989 · ''The passenger said that all the survivors are in good health and that the crew of six survived,'' an Aeronautics Ministry spokesman said in a ...
[21]
Lost Over the Amazon: The Tragic Journey of Varig Flight 254
Sep 29, 2024 · The crash killed eight people instantly, while others were left critically injured. The nightmare was far from over for those who survived the ...
[22]
BRAZIL CRASH SURVIVORS TELL OF 'MIRACLE'
Sep 6, 1989 · Although an air force statement said nine people had died, the airline Varig later said 13 were missing or dead from a total of 54 passengers ...
[23]
Perdido na Amazônia: 35 anos do voo Varig 254 - Flap International
Sep 3, 2024 · A aeronave caiu bem distante de seu plano original, a cerca de 1.000 km de Belém, em São José do Xingu. Dois dias depois do ocorrido, um ...Missing: memorial comemoração Félix
[24]
"Air Crash Investigation" Vanishing Act (TV Episode 2015) - IMDb
Rating 7.7/10 (136) 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.
[25]
Varig (Airlines Series): Lloyd, Barry: 9781802822502 - Amazon.com
This book details Varig's extremely modest beginnings in a small corner of Brazil, its journey to become one of the world's major carriers and its ultimate ...