Varig Flight 254 was a Boeing 737-241, c/n 21006/398, registration on a scheduled passenger flight from São Paulo, Brazil, to Belém, capital city of the state of Pará in the country's North Region, on 3 September 1989. The flight had several intermediate stopovers, the last being in Marabá, Pará. Prior to takeoff from Marabá, the crew entered an incorrect heading into the flight computer, flying deep into a remote area of the Amazon jungle. Attempts to reach an alternative airport were unsuccessful and the plane eventually ran out of fuel, crashing during a belly landing in the jungle northwest of Rio de Janeiro. Of the 54 passengers and crew, 12 passengers died and many more sustained serious injuries. The survivors were rescued two days later.
Background
The flight was a scheduled service from São Paulo to Belém with stopovers in Uberaba, Uberlândia, Goiânia, Brasília, Imperatriz, Marabá, and finally Belém. The São Paulo–Belém route had an approximate duration of eight hours and 20 minutes. At 9:43, flight 254 left Guarulhos International Airport, São Paulo, heading towards Belém. The flight crew consisted of 32-year-old Captain Cézar Augusto Padula Garcez, First Officer Nilson de Souza Zille, 29, and four flight attendants. The flight went smoothly through all the stops, and at 17:20, the crew was arranging the final preparations at Marabá Airport while the passengers were boarding.
Incident
While First Officer Zille was making an external inspection of the aircraft, Captain Garcez consulted the flight plan for the magnetic heading to Belém; the flight plan read 0270. Garcez interpreted this as 270°, but it intended to mean 027.0°. Varig's heading notation for the flight plan was changed to four digits from three while Garcez was on vacation, and it did not explicitly specify the position for the decimal point, which was implicitly located between the last two digits. That confusion was the primary cause for the disaster, along with other minor errors. The captain, therefore, set the left-side horizontal situation indicator (HSI) to 270°, i.e. a due-west course. This heading is clearly inconsistent with a route from Marabá to Belém.
After setting the HSI, Garcez programmed the aircraft performance management system (PMS) to the distance to Belém (). The flight plan indicated an altitude of (FL290), and a leg duration of 48 minutes. When co-captain Zille got to his seat, instead of checking his own flight plan to adjust his HSI – as he was required to do – he only referenced the captain's indicator and set his to match it. At 17:45, flight 254 took off from Marabá, and the autopilot steered the aircraft to a heading of 270° away. When Garcez believed the aircraft to be close to the destination, he attempted to use his VHF radio to communicate with the Belém tower. Failing to do so directly, he used another Varig airliner operating flight RG266, as a radio relay to talk to Belém Airport. When Garcez managed to establish communications with Belém, he requested descent clearance, and received it. Upon performing his descent, the captain found it very odd that he could not recognize any of the characteristic geographical features of the Belém area (such as the Marajó Island and the Amazon River estuary), and even asked the tower controller if the city was without electricity. In 1989, Belém airport still had no radar, so the controller informed Flight 254 that it was the only one in its airspace, and gave it landing clearance.
After the PMS started indicating negative distance to its destination, Captain Garcez decided to execute a 180° turn and locate Belém visually. He also descended the aircraft to and reduced its speed to . Reluctant to use the HF radio to request help, the captain decided to take visual reference from a river he located below the plane, believing it to be the Amazon. The river was actually the Xingu, which runs chiefly south-north, while the Amazon runs west-east.