Accident Boeing 737-241 PP-VMK,
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Date:Sunday 3 September 1989
Type:Silhouette image of generic B732 model; specific model in this crash may look slightly different    
Boeing 737-241
Registration: PP-VMK
MSN: 21006/398
Year of manufacture:1975
Total airframe hrs:33373 hours
Engine model:Pratt & Whitney JT8D-17A
Fatalities:Fatalities: 12 / Occupants: 54
Aircraft damage: Destroyed, written off
Location:São José do Xingu, MT -   Brazil
Phase: En route
Nature:Passenger - Scheduled
Departure airport:Marabá Airport, PA (MAB/SBMA)
Destination airport:Belém/Val-de-Cans International Airport, PA (BEL/SBBE)
Investigating agency: CENIPA
Confidence Rating: Accident investigation report completed and information captured
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 São Paulo to Belém with an en route stop at Marabá. When the aircraft was preparing for departure at Marabá, 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 Marabá at 17:25. The aircraft climbed to FL290 and maintained the 270 radial of Marabá for about forty minutes. The flight was then cleared to descend to FL200 by Belém 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 Belém, 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.

Accident investigation:
Investigating agency: CENIPA
Report number: final report
Status: Investigation completed
Duration: 1 year and 7 months
Download report: Final report


Aurelio A. Santos
ICAO Adrep Summary 5/89 #11



photo (c) via Werner Fischdick; Rio de Janeiro-Galeao International Airport, RJ (GIG); October 1983

Revision history:

22-Mar-2024 14:49 ASN Updated [Accident report]

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