Investigation Summary
The accident was rooted in a change to Varig's computerized flight plan format. The airline had recently transitioned from a three-digit heading notation to a four-digit format that included a tenth of a degree without a decimal separator. Captain Garcez, who had been on vacation during the implementation of this change, misread the required heading of 027.0 degrees as 270 degrees. This error was compounded by First Officer Zille, who failed to independently verify the heading and instead cross-checked his HSI against the Captain's already incorrect setting. During the flight, the crew ignored several red flags, including the inability to receive Belém's VHF radio and NDB signals, and the fact that the sun was setting in front of them rather than to their left. They eventually tuned into a radio station they believed was in Marabá, but was actually a station in Goiânia, over 1,200 km away, which shared the same frequency. This led the crew to fly even further south until the aircraft ran out of fuel.
Final Conclusions
The CENIPA investigation concluded the primary cause was pilot error stemming from the misinterpretation of the flight plan and poor cockpit coordination (CRM). The crew failed to perform basic navigational cross-checks and ignored environmental cues that contradicted their assumed position. Contributing factors included the confusing layout of the computerized flight plan and the lack of proactive monitoring by Varig's ground dispatch when the flight became significantly overdue.
Video Analysis
Plane Crash in the Amazon Jungle | Mayday Air Disaster — An investigation into how a navigation mistake and incorrect compass heading led Varig Flight 254 to run out of fuel and crash into the Amazon rainforest.
If playback is blocked, the owner has disabled embedding — use the link above.
Airframe & Maintenance
Crew Experience
Captain
Sentenced to community service for his role in the accident.
First Officer
Sentenced to community service for failing to independently verify the flight plan.
Systems & Failure Modes
Horizontal Situation Indicator (HSI)
The primary navigation instrument where the incorrect 270-degree heading was manually entered by both pilots.
Performance Management System (PMS)
Used to track distance to the destination; it began showing negative values when the aircraft flew past the calculated distance for the Belém route.
Automatic Direction Finder (ADF)
The crew used this to tune into NDB beacons, but mistakenly identified a distant station in Goiânia as their intended waypoint.
Interesting Facts
- 01The flight plan notation '0270' was intended to mean 027.0 degrees, but the lack of a decimal point led to the 270-degree error.
- 02A post-accident test by IFALPA showed that 15 out of 21 pilots from major airlines made the same reading error when presented with the Varig flight plan.
- 03The aircraft was located by search teams 44 hours after the crash.
- 04The crew flew for over three hours on a flight that was scheduled to last only 48 minutes.
- 05The forced landing was conducted in total darkness with only basic standby instruments functioning after the engines stopped and batteries depleted.
- 06After the crash, four survivors trekked through the dense jungle for several kilometers to find help, eventually reaching a farm to alert authorities.
Safety Actions & Advisories
Navigation System Upgrades
Varig installed Omega navigation systems across its fleet to provide more reliable long-range positioning data.
Flight Plan Format Revision
The airline revised the graphical representation of computerized flight plans to clearly distinguish between degrees and tenths of degrees to prevent reading errors.