A simple but MASSIVE mistake! | Varig Flight 254

Ladies and gentlemen, this is your captain speaking, we have no idea where we are, where we are, these are probably the last words you want to hear from your pilots and yet a variation of this is exactly what the passengers on the

flight

got varg 254. Now, what led to this absurd situation is both a fascinating story about the limitations of the human mind and a lesson in how not to act in a cockpit. Pay attention. September 3, 1989 was a pleasant, mostly clear day over central Brazil. There were only scattered clouds around, but the continued burning of rainforest to clear land for agriculture was causing in some localized areas what is known as dry fog or smoke.

At that time, the dominant airline in Brazil was Varig, which operated a large fleet of Boeing aircraft, including the Boeing 73700, which was a true national workhorse, at that time it was still common in Brazil to operate

flight

s in the form of a train. , starting the flight in one city and then making intermediate stops at different smaller airports where passengers could stay or disembark depending on where they were traveling, if you were unlucky and wanted to fly to the final destination, this could mean quite a long trip that It lasted all day and it was in this way that flight V 254 was operated.

It had started in Sa Paulo in the morning and had then operated north through Ubera Uberlandia Gu and then Brasilia, where a change of cruise was scheduled, The flight was then planned to continue to Imperatrice Maraba and finally BM, which was situated near the Atlantic. coast next to the mouth of the Amazon River, the two pilots taking charge of the flight had been spending their time awaiting the arrival of their plane reviewing the weather forecasts and flight plans for the next three flights, the weather was as I mentioned before very pleasant and the departure time was also quite civilized, so they were both in very good spirits when the day of duty began and it seemed that everything was going to be quite

simple

.

When they checked the Nots there wasn't much written except that an NDB called crj karakas was inoperative and had been for the last 4 months an NDB is a non-directional beacon and is one of the least sophisticated craft we use in aviation basically It works by sending a continuous radio signal typically between 150 to 530 khz which is then interpreted by the aircraft's automatic heading finding ADF instrument which turns a needle towards that beacon. It is a very crude instrument that may make any new instrument pilot break out in a sweat when they think about using it for holding or approaches, but it generally does a very good job like any other navigator we use, it also transmits an identifying Morse code that pilots We must listen and check before using it for navigation and since it transmits at lower frequencies than other beacons, it has a fairly long range. which can slightly follow the curvature of the Earth, but this also makes NDBS very sensitive to environmental perturbations such as obstacles from storms and the ionospheric layer in the ATM atmosphere.

Remember that, in any case, it seems that the two pilots did not look too closely. One particular Note and an inoperative NDB were not a big problem, since for most of the three flights there were other more accurate VR beacons available and this particular NDB was not even planned to be used on any of those routes, furthermore, the weather was really nice. The captain was fairly confident that he could navigate visually if necessary using the lower level navigation charge they had in 1989. The aviation infrastructure, especially around remote rural areas in the Amazon rainforest, was very sparsely built, so navigation was partial.

Visually it wasn't as uncommon as it is today, on top of that there was also a complete lack of radar coverage for a large portion of the Light 2's upcoming fire force voyage and GPS was not available, but it would still be several years. before that became a standard on almost all aircraft and that's also worth remembering who the pilots were who were going to operate these flights so well the captain was 32 years old and had been flying for

varig

for the last 7 years before Although he had been operating for the Brazilian Air Force and then flown on the Boeing 727 before eventually becoming captain of the 737, almost exactly a year before this flight, he had a total flight experience of just over 6,900 hours of flight time. of which 980 had been flown on the 737, its first officer was He was 28 years old and much less experienced.

He had only been employed with the airline for a little over a year and had started flying the Boeing 737 very recently, in March 1989. This meant he had flown just under 900 hours in total and only 442 hours on the '73. Now it's pretty safe to say that with the strict hierarchy that existed in

varig

at the time combined with the captain's previous military background and the first officer's little experience, the power gradient between these two pilots was probably quite steep, but that's not clear. highlighted in the final report. I should also mention here that I am basing this story on both the final report and some eyewitness accounts, including the first offices, since the report itself was not very detailed anyway when the plane finally arrived in the early hours of In the afternoon, the two pilots were ready and went out to meet the plane on the apron.

It was a beautiful 73700 with its cigar-shaped low-bypass Delta JTA engines howling in the wings as it approached the pad. The pilots let the passengers. They disembarked before entering the plane they greeted the cabin crew and then spoke a bit with the departing pilots, they reported that the plane had been performing wonderfully and that there were no open technical problems with it, so with that good news The pilots thanked their colleagues and we began to prepare the plane for departure, where the first officer would pilot the first leg and the captain would fly the next two. All checks went smoothly and that meant the plane soon took off for the first flight to Imperatrice. and then to Marabá, these flights were uneventful except that the captain encountered some difficulties landing at Marabá due to a dense layer of smoke that had moved over the airport;

Visibility through that smoke had been made even worse by the fact that they were landing in the late afternoon, but the sun would have illuminated the smoke at a very low angle anyway. They finally managed to land and then taxi and while some of the passengers disembarked, the first officer went outside to walk around while The captain began preparing the plane for the final short 40 minute hop to BM. Now this last leg was a little different from the previous ones because there was no published airway connecting the two airports to each other. The airways are like highways in the sky and are clearly marked at low and high IFR loads, which we pilots always have access to the airways, especially back then we usually went between different ground navat with the headings between them clearly marked.

The captain was very used to sailing using these CHS. but since he couldn't do that on this leg, he had to look down at his flight plan, which also included the headings between the different waypoints. In this case, he was especially looking for the first magnetic course to follow after the departure and here we go. One of the first clues to what caused this debacle is that Varig had only a few months earlier begun operating aircraft with an autopilot system that was capable of accepting heading data with an accuracy of up to a tenth of a degree, the Boeing 737, however, could not. do that, but to keep things common across the fleet, the airline had started issuing flight plans with courses represented as a four-digit number instead of the standard three digits, but for some reason they hadn't included any commas. or decimal point on those four figures to highlight the fact that the last figure was a tenth of a degree and this meant that when the captain, probably for the first time since this new format was introduced, looked down at his flight plan to find that first heading, what he saw was 0270 this was supposed to mean 027.0 meaning a north-northeast leg to follow towards BM, but it's pretty easy to see how it could be interpreted as 270 degrees, so, without thinking about it any further, the captain installed a bug on his 270-degree HSI horizontal situation indicator to remind him which heading to follow after departure and then simply continued with his setting.

Now I'm guessing many of you are spitting out your coffee because even with very limited navigation knowledge, most of us know that 270° is a straight course due West and that would make absolutely no sense if you intend to sail to a destination. in the Northeast, but this is exactly what happened after this, the next thing the captain had to configure was a relatively new system on the 737 known as the performance management system or PMS for short, it was a crude predecessor of the Flight management designed to help optimize the flight profile of the aircraft based on performance data and distance to the destination the system would help calculate when it was time to begin descending give inputs to the external throttle and inform the pilots about things like fuel efficiency etc., but the PMS was not connected to the navigation system per se, it only counted the distance flown from the total distance entered, so the captain entered 178 miles to the destination from his flight plan and then began final preparation of the flight deck while the first officer had been outside and when he returned to the cockpit he looked at the same flight plan and also looked at what the captain had configured his HSI and simply copied it on your own instruments Now, when you plan to fly an airplane according to IFR instrument flight rules, you must configure the instrument so that the airplane can fly and navigate safely without any external. visual references in this case that would have required the pilots to tune the navigation systems they were going to use on the Route, which consisted of an NDB beacon near the runway in marabá and a more precise VR beacon at their destination now than virtual reality could be available. range at the beginning of the flight, but there was also another VR near the tukuri route that could have been used as a check.

We don't know exactly what kind of output the captain made or if he made any, but in any case, he didn't include those naats because they were never tuned. Instead, it seems that the captain thought the weather was so good that it would be easy to visually find the BM airport if he simply continued on his initial course. That type of navigation is This is known as dead reckoning and is normally used when there is a complete lack of navigation so all you really have are clues and times, perhaps you could argue that the captain had a time here since PMS was primed and ready to attack him, but if I'm going to do this, which is very rare, by the way, you better make sure you stay on the right path.

In any case, I highly doubt that an actual exit briefing took place, as that would definitely have highlighted the absurdity of that initial meeting. runway they were now planning, but instead the last 48 passengers were boarded, giving a total of 54 passengers and crew on board when they finally began to taxi towards the exit into the sunset and I will tell you everything that happened after these

mistake

s. It happens, that is something you will soon see and it is part of being human, but as a pilot I always try to look for tools and strategies that help me avoid those

mistake

s and make my life a little easier.

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In fact, my wife signed up immediately when I said thank you incognate. Now let's continue, as the 737 guy was leaving and started approaching the holding point. The pilots were busy completing their final cockpit checks before departure. Several of the passengers in it were actually. nervous because at the same time that Brazil was playing Chile in a decisive qualifying match to determine which of the two teams will play in the 1990 World Cup, some of the passengers asked the flight attendants if they had heard anything about the score and this was revealed. He relayed it to the pilots, who in turn asked traffic control about it.

Now this is something that happens almost all the time, even to this day when important matches are played and ATC is usually very helpful if they have the time they had in this case meaning the pilots were able to give the passengers an update of the game and this fact actually led to one of the first theories about this accident that the pilots were actually listening to a football game in the cockpit when in reality they were simply told that information. them by ATC and that is what those Witnesses misinterpreted anyway when we are on the subject of air traffic control, the airport in Marabá was not controlled, so the only ATC interaction the pilots had was with an officer of the flight information service which was sitting in a separate building. away from the track it did not have any access to any radar screen or other advanced tracking equipment, instead its only job was to provide weather and traffic information and apparently football scores, but that meant that when the pilots were ready to take off reported the FIS officer, who probably simply gave them the clear runway along with the latest wind information, after that it was up to the flight crew to depart at their own discretion and then finally, switch to the BM controller once they had gained some altitude at that point.

At 1735 local time, the captain first stabilized the engines at 1.4 epr and then established takeoff thrust, causing the 727 to begin accelerating down the runway. The takeoff was completely normal and after reaching about 1,000 feet, the captain called for the flaps to be retracted and then took off. turning onto its first indicated trajectory of 270°, since this was late afternoon, that initial trajectory would have meant the plane was turning directly into the Setting Sun glowing bright orange through the dense layers of smoke. Now this should have served as a first trajectory. indication that something was definitely wrong, both pilots should have known that their destination was located north of them, meaning that some kind of basic spatial awareness should have come into play here, but unfortunately it didn't, the pilots just They concentrated on completing post-takeoff checks and continued their climb to the planned Cru altitude of flat level 290 or 29 9,000 feet.

When they rose above the smoke layer, the Amazon rainforest began to spread out before them in the fading sunlight. As expected, visibility was good, so the captain was confident that he would be able to visually find his way to the destination. He looked at his PMS, which showed that the nautical miles remaining to the destination were decreasing as expected and this probably just reaffirmed his feeling that he was on the right track, but remember that this PMS was only counting miles flown, not whether it was flown in. the really right direction. Now, if the maraba and BM navat had been tuned, they would have clearly shown that something was very, very wrong, but since they weren't, they weren't. of any kind of use here after the flight continued the pilot soon tuned the BM V to start receiving guidance towards the airport but strangely it didn't seem to work, this initially confused the pilots who knew they should now be fine. within the range of that beacon and therefore they decided to contact the BM air traffic controller to check if the VR status was okay, but when they did so initially there was only static h on the frequency, this was really strange, so which the pilots began to suspect that perhaps they were suffering from some type of radio malfunction.

They began to look at the circuit breakers that were located behind them, but none of them had blown and everything else seemed to be working as it should. The captain then suggested they try the HF radio. instead of their normal VHF radio and when they did they finally managed to contact the aeronautical information service officer at BM, this caused some initial confusion as this AIS officer was sitting in a separate room in the tower, away from the active controllers, but finally managed to start transmitting information between the aircraft and the actual controller in charge, meanwhile the pilots continued trying to use their normal radio and managed to contact another approaching aircraft. 2 BM that aircraft reported that the navigation seems to be working fine and that they could talk to the bblm controller without any problems, obviously this was all very confusing for the pilot, but if we look at what was really happening here, everything has a lot sense since the plane had been flying for over 20 minutes in the wrong direction, it meant that they were now well out of range of both the VR in BM and the controller's normal VHF radio; the HF radio was operating at a lower frequency and therefore had a significantly longer range, so they were able to come into contact with that AIS officer and the fact that they were able to reach that other aircraft was probably due to both the position of that aircraft, which could have been closer to them, as well as the fact that it was significantly higher up, which helped extend the distance.

In any case, the captain was now looking out his window trying to locate a distinctive bay next to BM, but no matter how much he squinted, he still couldn't locate anything, the only thing he recognized was the sunset in the west. and the dense jungle below them they had already been flying for 23 minutes and as it was only supposed to be a 40 minute flight the PMS indicated that they had already passed the ideal point to start descending, the captain saw this and The first officer asked the controller for an initial descent clearance, the first officer complied and sent this request over the HF radio to the still confused AIS officer, who managed to get confirmation from the controller that they could indeed begin descending. initially down to flight level 200.

This very confusing situation had also meant that there had been no time for proper approach training or checking any other intermediate navads, so when this descent began, they were still essentially flying blind and now it was starting to get dark outside the plane as well. They continued flying with the pilots anxiously scanning the horizon in front of them for any sign of their destination and when they looked down their TDC soon showed that they should be over their BM and then that they had passed it with 5 10 20 miles, how could? Maybe they had entered the wrong mileage into the PMS or something.

The AIS officer continued by asking them to try to communicate with the BM air traffic controller directly on the VHF frequency, but everything the pilots could hear on that was of no use. the radio was static and the occasional call from some other aircraft when the PMS finally showed that they had flown over the destination by 30 nautical miles, the captain assumed that they must have somehow missed the airport and therefore changed their course and began to fly back the same way. They had come not to miss it again. Now they also asked an officer to convey a request to descend to an even lower altitude, up to 4,000 feet, because from that height they should definitely see the airport.

I think it's really interesting to see. how strong confirmation and denial bias can be here, these two pilots now thought they must have overflew their destination and somehow missed it knowing full well that 30 nautical miles beyond their destination they should have been over the Atlantic Ocean, which they clearly were Not yet, they now descended towards the east in the hope of being able to see the destination airport which, logically, could not be below them at this point. They had also flown longer than the total planned flight by almost an hour. in the wrong direction and descending to a lower altitude will now counteract the much denser air, which would greatly reduce the remaining range, but the captain was not worried, he was very confident in his navigation skills and, according to the first officer who now had begun to seriously doubt his position, the captain was also arrogant and simply dismissed his concerns.

At this point, they had about 1 and a half hours of fuel left, which should have been enough to get them back to Marabá, the airport they had just left, if they had. I tried, but instead of trying, the captains seemed determined to take them and the passengers to BM. This is something known as get aitis, which could have been caused by the captain's fear of repercussions from the airline if he did not complete the flight like they did. Now they were descending, the first officer continued to try to find something to navigate and remembered that there were a couple of commercial radio stations on BM broadcasting frequencies that the ADF team on the aircraft could tune into if they could find those stations in the future.

The ADF needles would start pointing towards those transmitters and that would make them finally able to find BM. The first frequency he tried came just with a broadcast covering that football match we talked about earlier, but the second came loud and clear playing a live Sunday Church Service, the frequency of this broadcast should have belonged to liberal radio on BM and As soon as the signal was received, the ADF needle began to point directly south, while the first officer fiddled with this, the captain still looking outwards. As The Descent continued and he saw a large river suddenly spreading from left to right in front of him, perhaps this could be the Amazon, if that were the case.

Milan knew he would lead them toward their destination if they could only figure out which direction. turn and that was soon decided with the triumph of the officers' first attempt to turn on liberal radio, so suddenly they now had a river and an instrument pointing which way to turn, so with a Sunday sermon broadcast through the receiver ADF and the aircraft that descended through 10,000 feet now turned their aircraft to the right and began following the river southwards again. Here it is probably worth noting that the Amazon River is probably one of the best known features of the Brazilian landscape and pilots.

He must have known that it flows from west to east, so again, how would it make sense to follow a river south? This is just one more example of how confirmation bias works, where only indications that confirm the bias are considered and everything else that speaks against it is ignored. Now it was almost completely dark outside when the plane stabilized at 4,000 feet and turned. to follow the turns of the river the two pilots looked anxiously out waiting for the city lights to appear behind each new turn but they never did so obviously something was still very wrong if they had simply failed and flew past the airport initially it should remember that the initial heading towards BM was supposed to be a reasonably low number, which meant a safe heading and when Now he looked out he could clearly see the Southern Cross constellation ahead of them.

What was happening, the captain obviously must have thought exactly the same. So he asked the first officer to find the low level navigation short and take a look at the correct trajectories and when they finally found it they realized his mistake. They had been flying 270° after departure instead of 0.27°, which meant that the river they were now following couldn't be the Amazon, they were actually following the Singu River, but they obviously had no idea about that and neither. I can't even begin to understand the feeling these two pilots must have now felt. their stomachs had flown their plane full of people in the completely wrong direction for over 2 hours and now we are following a familiar river into the jungle as their fuel was steadily decreasing since they had left, they had gone around so many timesand turns that Even if it had initially been possible to find the way back to Marabá, it would now be almost impossible without the help of some kind of reliable navigation, but what about the ADF and that radio signal they had been following well here?

It would almost become comical if it weren't so sad because it turns out that the radio signals they had been receiving were not coming from BM as they had assumed, but from another radio station called radio club de gu which was using the same frequency but was located in a city ​​called gu hundreds of kilometers to the south. Now that station should theoretically be out of range, especially at that low altitude, but due to the atmospheric conditions tonight the signals had bounced off the ionosphere greatly expanding their range. By the way, this is why it is not a great idea to use signals from commercial radio stations for navigation, since it is very difficult to verify their true origin.

The pilots obviously didn't know they were tracking a false signal, but they did know. Time was of the essence, they needed to figure out where they were fast, otherwise they would run out of fuel before they could reach any airport. By the time they realized their mistake, they had been flying at 4,000 feet for 1 hour and 14 minutes, meaning that the total time they had then been in the air was 2 hours and 10 minutes in one flight. which had been planned to last only 40 minutes. They had obviously carried some extra fuel, but it was now less than 1 hour before they were running completely dry, esp.

If they were to continue flying at this low altitude where fuel consumption was significantly higher now, you would think that the pilots in a situation like this would make a mayday call and try to gather any help they could get, but that didn't happen as I mentioned before that it didn't. There was radar available in the area so there wasn't much ATC could have done anyway, but maybe they could have come up with some valuable suggestions or at least now they would know the aircraft was completely lost, controllers on bam. The uncertainty phase had begun when the plane had not yet arrived an hour after its takeoff time but had arrived a full hour.

The emergency had not yet started, the pilots knew they had to do something, so the captain began a climb. at 8,500 feet to try to make contact with some NDB ships at Maraba or perhaps Karakas airport further south, and when when those frequencies were tuned, they actually picked up signals again telling the pilots to turn to the south now that there were only 1,800 kilos left of a few, but in another cruel Turn of Fai it turns out that what the ADF receivers were actually picking up here were None of those naats that the pilots expected remember that the karakas andb had not actually been so inoperative and maraba was now too far away.

Instead, those signals belong to NBS in gu and b garas that were using the same frequencies and those signals also bounced off the ionosphere going much further than they were designed to now, the pilots would have known if they had taken the time to do so. time to listen carefully to the morse code identifiers of those navats, but confirmation bias is, as I mentioned, a very powerful thing and In the situation they were in now, they probably refused to accept any indication that counteracted their own mental model. of what was happening. Soon the Captain asked the First Officer if he could try to locate the L3 low level navigation chart while he had a feeling that they might be somewhere in that area southwest of Maraba, which was actually a very good guess. .

The first officer tried to find that shot, but in the dark cockpit and under this extreme stress he never managed to find it and that was very unfortunate. because if they had, they would have discovered that they were actually still within range of another airport, a military base called Kashino, about 100 nautical miles away, but since they couldn't find it, they simply continued on their sudden course chasing those faulty ndb . Minutes continued to pass in what must have seemed like hours and soon the terrifying reality began to set in: they were going to run out of fuel and would have to make a forced landing in total darkness in the dense Amazon rainforest, now this realization did not come.

This caused the pilots to begin to panic and make no particular preparations for the upcoming accident. Instead, a feeling of resignation began to spread and they were both heard saying things like maybe this is nothing more than a dream, this clearly shows something known as dissociation, meaning that I didn't feel like this was happening or that it was real or happening to them, which is often the case with people who are experiencing severe stress, apart from the fact that they could also be heard talking about a possible Compass glitch that had caused them to make this horrendous mistake, but given Since the CVR only recorded the last 30 minutes of the flight and they had already realized what had happened long before the conversation took place, it is very likely that those comments were made to be captured on the CVR on purpose to deal with.

To hide what had really happened from the investigators anyway, since an accident now seemed inevitable, the captain also took the PA microphone and for the first time on this long flight explained the situation to the passengers, now he obviously couldn't tell that. They had made a mistake, so he told them that they had experienced a navigation malfunction and would therefore soon have to make a forced landing in the rainforest. Now the final report did not specify how the passengers reacted to this, but according to some witnesses they report that two very different responses occurred almost immediately, a large part of the passengers remained silent and began to cry softly, while some joined their hands in prayer, while other passengers burst into the forward galley and began helping themselves to various alcoholic beverages.

This must have been horrible. situation for everyone, especially for the cabin crew who now had to prepare and the passengers for an emergency landing in the total darkness of the jungle, there was still not much action in the cabin. Both pilots stared in horror at their fuel gauges as Now they were both rapidly approaching the void, so what could they have done here? Well, if you know that you are about to make a forced landing, there are actually quite a few things you should do, first of all, you should inform Air Traffic Control about what you are going to do so that they can alert search and rescue resources. , then obviously you have to prepare the cabin crew and inform them so that they can maximize the cabin preparations and inform the passengers on what to do with the emergency exits and demonstrate the support position etc.

Secondly, the The cabin should be configured accordingly and a crash briefing should be conducted including what settings to use, speeds to follow, and what area they should search. Yes, I know it was all black outside at this point, but the weather. It was also clear, so by minimizing the cockpit lighting there was still a chance that I could make out some features in the landscape or maybe even target some lights in the distance instead of just flying blindly in a straight line. Another thing to remember is that it is always best to execute a forced landing with the available engine power that will maximize maneuverability and minimize descent rate so that once again the crash location can be more closely monitored and the gForce minimized.

Additionally, having two engines running would also ensure that all systems, instruments and lights would be available to them, so with that in mind, it would have been best to use the last remaining bit of fuel to land the plane, but that unfortunately did not happen. Here, the pilots also did not tell their traffic control about how serious their situation really was or about their crash landing plans and that was despite the fact that they probably had contact with ATC via their HF radio until close to the Finally, the fact that the captain had guessed that they were somewhere on the L3 map could have been very useful information to share with a controller, for example, remember the golden rule of aviation, aviate, navigate, communicate well, Not much of that was being done here now, the pilots discussed how they were going to execute the landing, but without actually looking for some guidance in their manuals that would probably have given them some valuable advice, they decided to let the fuel run out completely and then glide toward landing, concentrating on trying to minimize vertical speed just before reaching the treetops, but with that.

In the plan they also ignored some very important technical aspects that will come into effect when the engines shut down, as you will soon see at around 20:35 local time, the plane had flown for almost exactly 3 hours and the fuel had now been reduced to only 100 kilos . The pilots had turned on the Apu's auxiliary power unit to provide electrical power, but of course that also required fuel to operate the left engine. Engine number one was the first to shut down and when that happened the pilots began their descent from 8,500 feet. They were now flying on a heading of about 165°, following the indications of those false NDB signals and only about 1 minute later, engine number two also failed, which was done quickly, followed by the Apu shutting down, causing everything to the plane left.

Almost completely dark, except for the backup instruments in the cabin and the battery-operated emergency exit lights, the only thing that could be heard now was the wind blowing outside and the screams of the terrified passengers in the rear without no engine. The plane descended at around 1000 feet per minute and the captain tried to maintain speed just above the stall speed as the trees began to get closer and closer beneath them, the first officer continuing to indicate altitudes and other parameters as that stretched out and the captain soon asked. so that the flaps would be extended so that they could begin to slow the plane when the first officer heard this he selected first flaps one and then flaps 5, but due to the lack of fuel in the tanks that normally cools the hydraulic pumps , these pumps now started to overheat.

As soon as this was sent the associated pump automatically shut down but the system still continued to produce some pressure through the movement of the engines but this shutdown also produced a low hydraulic pressure warning in the cockpit and when the first officer saw this, he instinctively reached out and turned off the associated pump switch, although that would have been the correct thing to do under normal circumstances, in this case it meant that the isolation valve on that pump opened, which then completely removed pressure from the system. hydraulic, which in turn meant that the flaps were stopped in position two and could not be extended further, fortunately the B pump switches were left alone, which meant that there was enough hydraulic power to actuate the flight controls that otherwise they would have reverted to something known as manual reversal where pure muscle energy is needed to move the surfaces of the Ruder and I can tell you that is really very heavy during the last few meters over the trees, the speed was around 115 knots and the descent speed of approximately 800 feet per minute as there was only battery power.

The landing lights were also not operational, which meant that the jungle would have only been seen as a deeper blackness that was now approaching them, the pilots had no idea if they were going to land on water, trees, rocks or swamps, all what they could do at this time. The goal was simply to hunt and continue flying their planes, the landing gear was never lowered and it's actually quite difficult to say what impact it would have had if it were that way normally. It is always recommended to extend the gear when landing on the ground as it will absorb some. of impact forces but that's when the engine is actually running in a situation like this the gearing would obviously have created more drag which would have caused a higher rate of descent and it's unclear how much impacting the cups would have actually helped In any case, the pilots did not even discuss any of this at the time 2050, the bo 77 finally impacted the treetops 30 to 40 m high in the dense jungle canopy, this immediately It tore off both wings and hit the bottom of the plane causing the cockpit to collapse.

The floor began to warp upward without the wings, the cabin continued to slide forward past the trees until it hit the ground with a thud, stopping everything completely in a matter of meters, the planehad finally crashed, but this story was still far from The deceleration force during the accident was calculated to be about 15 g, meaning it was far beyond the maximum force the plane had been certified to be able to withstand, which caused some of the passenger seats to become detached from their attachments and then fly away. It moved towards the forward bulkhead, immediately killing eight people and seriously injuring others, but as if by a miracle, 46 of the 54 people on board had initially survived the impact and as the worst confusion began to subside, they began attempting to evacuate and also to help the injured when the doors were open, some of the emergency exit SLS deflated immediately when activated as they were impaled by sticks and three on the outside and some of the passengers who jumped out of all modes began to run directly into the dark jungle fearing an imminent explosion but of course, a fortunate byproduct of As the fuel was completely exhausted, there was nothing left that could explode on top of the eight passengers who had died immediately, four more were seriously injured. and they just needed to be taken to a hospital as quickly as possible, but how was that going?

To be possible, no one knew where the air traffic controllers were, as many hours at this point they stopped all traffic heading to their intended destination, BM, to facilitate their eventual landing and had also, at the captain's request, reopened the airport at karakas but there was no sign of the aircraft anywhere, the formal search and rescue campaign began later that night when it was decided that the aircraft must have run out of fuel by then, but where should they start searching? of the plane and the pilots had not given the controllers any clues about where they were at the same time in the jungle the crew and surviving passengers had tried to help those still trapped in their collapsed chairs the captain was conscious and was helping to lead the effort, but the first officer had hit his head on the metal part of the back of his seat and was still unconscious at the time.

Now everyone tried to do what they could, but with the limited light and medications available there was very little that could be done. During the first few hours, as dawn broke, the captain managed to remove the emergency locator transmitter, the elt, which is a small device designed to send an emergency pulse on the emergency frequencies 1 to 1, 5 and 243 MHz, but unfortunately this elt was not of a type that was activated by g forces; instead, it had been designed to light up only after drowning in water and therefore had to be submerged in liquid. This meant that passengers and crew now had to use whatever little liquid they could find on everything, including I melted the bar and his own urine to try and submerge the device in a bucket to activate it and after a while it actually worked.

One of the passengers had a Walkman with them and with the help of it they could listen to the pulses. They were transmitting in the form of interference in their headphones but now they also had another problem, the lack of water, you see, even though the rainforest is thought to be a place with abundant water, that is not always the case, so that now they had to try to do it. something about that fortunately it turned out that one of the survivors was a young forest surveyor and with his help a small expedition was sent into the jungle and soon found a small stream of fresh water that was safe to drink and some of the passengers in fact too.

I went there to swim a little while the search was now in full swing and the satellites had been activated to listen for the emergency pulses that should be sent by the ELT soon faint signals could be picked up that guided the search. and the rescue teams far to the southwest of the aircraft were waiting for the flight path, but although a search plane was sent over that area nothing was found on the first day of searches, after the second night among the wreckage, the passengers decided they would have to try it. and to find help another expedition consisting of four passengers met to begin walking and to their surprise they only needed to move a few kilometers through the jungle before reaching an open piece of land that had been cut down and burned into farmland, there They found a farmer who, quite surprised, explained that he had no contact with anyone outside, but he thought that a neighbor a few kilometers away might have a radio amateur.

He took one of the passengers in his car and then took him there and along with that neighbor now began He initially broadcast his fantastic story through Airways, although no one believed him, so he had to keep repeating his ticket number numerous times until someone finally took him seriously. Once that happened, the entire rescue effort quickly converged on the site and with the help of those. four survivors the crash site was soon located from the air this happened 2 days after the crash and 1,100 km southwest of where they should have been a helicopter transported the rescuers to the scene but as the light was fading rapidly the survivors had to endure another night in the wild, but this time with food blankets and medicines available and sadly three other passengers had succumbed to their injuries by that time and one who was later airlifted to the hospital also did not mean that 12 people in total died like Como result of this accident, but miraculously the other 42 passengers and crew had survived not only the accident but also the 48 hours lost in the jungle, the investigation began immediately and it soon became clear that this accident had been caused by a combination of a lost.

Pilots' navigation error, partly due to unclear flight plan, this was followed by several human factor-induced errors and decisions that caused the pilots to concentrate on their goal of reaching BM rather than trying to invent a new plan to ascend to higher altitudes. and make full use of air traffic control and ships, this was a true testament to how easy it is to dig deeper into a hole when the right thing to do is to get out, look around with a new perspective and then start again, obviously . This type of event probably would not have occurred today with the availability of extensive GPS radar coverage and about a thousand other tools, but the principle remains the same.

Sometimes it is much better to ignore the S-cost, simply admit a mistake, and then focus on a solution. Instead, several recommendations emerged from this accident, the most important of which was probably the mandatory inclusion of a g-activated emergency location broadcast on the aircraft and, obviously, navigation and CRM training for all VAR pilots, in addition. of the four-digit course description change in your flight plans I now want to give special thanks to Admiral Cloudberg, who helped me find a translated version of the original final report in Portuguese, as well as her excellent article on this accident. I will link her work in the description below and advise you. to check it out she is really cool also check out these videos below and join my patreon team if you want to discuss this accident in more detail directly with me and the rest of the patreons in our next zoom hangout have an absolutely fantastic day and see you next time goodbye