Incident Overview

Date: Sunday 3 September 1989
Aircraft Type: Boeing 737-241
Owner/operator: Varig
Registration Number: PP-VMK
Location: S?o Jos‚ do Xingu, MT – ÿ Brazil
Phase of Flight: En route
Status: Destroyed, written off
Casualties: Fatalities: 12 / Occupants: 54
Component Affected: Flight Control System (Specifically, the HSI and Captain’s Input)Flight Control System (Specifically, the HSI and Captain’s Input)
Investigating Agency: CENIPACENIPA
Category: Accident
On August 20, 2023, a Boeing 737-200, PP-VMK, experienced a catastrophic landing in the Amazon rainforest near Bel‚m, Brazil, resulting in the loss of 13 lives and 41 occupants. The flight, a domestic service from S?o Paulo to Bel‚m, was marred by a critical error in navigation that culminated in a forced landing. The aircraft was en route to Marab , and the captain inadvertently entered the wrong course, 270 degrees in his HSI, triggering a critical navigational deviation. The flight plan dictated a course of 027 degrees, but the pilot?s input was incorrect, leading to the erroneous course of 0270. The aircraft then descended to FL200, but the crew failed to establish radio contact and lost navigational aids. The pilot subsequently altered course to 090 degrees, following a river, and then to 165 degrees, creating a challenging navigational situation. The sunset and dense fog significantly hampered the pilot’s ability to perceive the terrain and navigate accurately. The pilot’s inability to recognize critical navigational cues, particularly the VHF bridge, contributed to the escalating situation. The loss of power due to fuel shortage further compounded the problem, leading to altitude loss and a forced landing in the dark. The aircraft was located 44 hours after the accident, and the pilots were forced to carry out a landing in the jungle, a situation that was initiated by the crew’s failure to establish radio contact and to locate navigation aids.On August 20, 2023, a Boeing 737-200, PP-VMK, experienced a catastrophic landing in the Amazon rainforest near Bel‚m, Brazil, resulting in the loss of 13 lives and 41 occupants. The flight, a domestic service from S?o Paulo to Bel‚m, was marred by a critical error in navigation that culminated in a forced landing. The aircraft was en route to Marab , and the captain inadvertently entered the wrong course, 270 degrees in his HSI, triggering a critical navigational deviation. The flight plan dictated a course of 027 degrees, but the pilot?s input was incorrect, leading to the erroneous course of 0270. The aircraft then descended to FL200, but the crew failed to establish radio contact and lost navigational aids. The pilot subsequently altered course to 090 degrees, following a river, and then to 165 degrees, creating a challenging navigational situation. The sunset and dense fog significantly hampered the pilot’s ability to perceive the terrain and navigate accurately. The pilot’s inability to recognize critical navigational cues, particularly the VHF bridge, contributed to the escalating situation. The loss of power due to fuel shortage further compounded the problem, leading to altitude loss and a forced landing in the dark. The aircraft was located 44 hours after the accident, and the pilots were forced to carry out a landing in the jungle, a situation that was initiated by the crew’s failure to establish radio contact and to locate navigation aids.

Description

Varig flight 254, a Boeing 737-200 registered PP-VMK, was damaged beyond repair in a forced landing in the Amazon jungle in Brazil. Flight 254 was a regular domestic service from S?o Paulo to Bel‚m with an en route stop at Marab . When the aircraft was preparing for departure at Marab , the captain inadvertently entered the wrong course, 270 degrees in his Horizontal Situation Indicator (HSI). The flight plan called for a course of 027 degrees. When the copilot returned from the walk-around check, he checked the course on the captain’s HSI and inserted the same course in his HSI. The flight took off from Marab  at 17:25. The aircraft climbed to FL290 and maintained the 270 radial of Marab  for about forty minutes. The flight was then cleared to descend to FL200 by Bel‚m ACC. However, the crew failed to find navigational aids and lost radio contact. Course was changed to 090 degrees as the aircraft further descended down to FL40. The crew then followed a river, heading 165 degrees. Because of the sunset and haze the pilot’s had difficulty navigating. Also, they failed to establish radio contact on several frequencies and failed to find navaids in the area. Just after finding two NDB beacons the engines lost power due to fuel shortage. The aircraft lost altitude and the pilots were forced to carry out a landing in the dark and without external references. At about 20:45 the aircraft made a forced landing in the jungle. The aircraft was located 44 hours after the accident. Forty-one occupants survived and thirteen had sustained fatal injuries in the accident. It appeared that the computerized flight plan used a four digit representation of the magnetic bearing with the last digit being a tenth of a degree without any decimal separator. A course of ‘027.0’ was presented as ‘0270’. Contributing factors a. Human Factor (1) Physiological aspect – Did not contribute to the accident. (2) Psychological aspect – The following psychological variables contributed to the accident: (a) Misleading perception – In the reading of the plan and incorrect heading insertion by the commander. (b) Reinforcement – In the reading and incorrect heading insertion by the co-pilot and heading conference placed by the commander. (c) Marginal attention and level of attention – The non-recognition of conditions that would mean being far from the objective: request for “VHF bridge” when other aircraft were talking normally with the Control; “reception” of commercial stations, and non-receipt of destination NDB, etc. (d) Predisposition – Mainting the urge to go to the established objective (Belem). (e) Predisposition duration – Maintenance of FL 040 for a long time. (f) Reinforcement of predisposition – Reception of boundaries when selecting Belem’s radio frequencies. (g) Attention Fixing – Permanent search for headings, radio contacts or river contours, as an alternative, to reach the fixed goal. (h) Blocks – Delays in identifying the initial headings error and plotting itself in navigation. (i) Geographical position error. b. Material Factor – Did not contribute to the accident. c. Operational Factor (1) Poor supervision – Inadequate graphical representation of the Computer Flight Plan. (2) Poor cockpit coordination – No supervision of cockpit activities. Actions were not supervised, but imitated. (3) Poor support staff – Lack of radio contact by the operator’s Flight Coordination with the aircraft in flight, after the significant landing delay in Bel‚m, thus breaking the chain of events of the accident. (4) Pilot aspect characterized by environmental influence – Difficulties of visualization due to sunset and dry fog: Radio aid markings received from great distances, originating from the ionospheric propagation of electromagnetic waves. (5) Pilot aspect characterized by poor planning – Lack of route letters to cross the flight plan information. (6) Pilot aspect characterized by poor judgment – Inadequate evaluation and use of radio-navigation equipment, resulting in the pursuit of markings without causing tuning and identification. (7) Pilot aspect characterized by other operational factors – Operational doctrine firming.

Primary Cause

Human Factor (1) Physiological aspect – The following psychological variables contributed to the accident: (a) Misleading perception – In the reading of the plan and incorrect heading insertion by the commander.Human Factor (1) Physiological aspect – The following psychological variables contributed to the accident: (a) Misleading perception – In the reading of the plan and incorrect heading insertion by the commander.

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