Lost and Confused: The crash of Varig flight 254

Admiral Cloudberg
29 min readJul 1, 2022


Note: this accident was previously featured in episode 27 of the plane crash series on March 10th, 2018, prior to the series’ arrival on Medium. This article is written without reference to and supersedes the original.

The cockpit of Varig flight 254 peers through the jungle where it came to rest after a forced landing. (Bureau of Aircraft Accidents Archives)

On the third of September 1989, a routine domestic flight in Brazil failed to arrive in the Amazonian city of Belém, its pilots reporting that they would make a forced landing before disappearing without a trace. Rescuers scoured the region surrounding the city, but found no sign of the Boeing 737 or its 54 passengers and crew, who had seemingly vanished into thin air. As days passed, the country demanded to know: where was flight 254, and why couldn’t anyone find it? The answer would stun all of Brazil: more than two days after the accident, a group of passengers from the missing flight arrived at a remote farm in the Amazon rainforest to report that the plane had made a forced landing in the jungle near São Jose de Xingu — more than a thousand kilometers south of Belém. When rescuers arrived, they found a mostly intact airplane and 42 survivors clinging to life in the rainforest, including the pilots. Their survival, as miraculous as it was, raised as many questions as it answered. Somehow, Varig flight 254 had taken off and flown for hours in completely the wrong direction, in what was quite possibly the most colossal navigational error in the history of commercial aviation. How could such a thing happen? What follows is a retelling of the legend of flight 254 and its antiheroic crew, in as much detail as the evidence allows, even as certain mysteries endure.

A period advertisement for Varig. (Vintage Airliners)

In 1989, Brazil’s oldest and largest airline, Varig, had a virtual monopoly on air travel in the country, controlling a large portion of the domestic market and almost all of the international market. Within its vast fleet, the most numerous aircraft type was, of course, the ubiquitous Boeing 737, a domestic workhorse which could be seen at every major airport in Brazil. At that time, Varig was still using its 737s to support a train-like route structure with numerous stops, a model which had already fallen out of favor elsewhere due to the rise of hub-and-spoke operations. One of these routes was flight 254, which originated in São Paulo before slowly making its way north with stops in Uberaba, Uberlândia, Goiânia, Brasilia, Imperatriz, Marabá, and finally Belém, near the mouth of the Amazon River.

PP-VMK, the aircraft involved in the accident. (Clint Groves)

In command of flight 254 on the 3rd of September 1989 was 32-year-old Captain Cézar Augusto Padula Garcez, a former military pilot who started flying for Varig in 1982. Joining him was 28-year-old First Officer Nilson de Souza Zille, a fresh hire who had been at the company for little over a year and had relatively little experience. The pair were scheduled to pick up the flight in Brasilia, replacing the crew who had flown in from São Paulo.

All went smoothly on their first two legs, and by that evening the two pilots and their Boeing 737–200 arrived in Marabá, managing to land despite a thick pall of smoke produced by local slash-and-burn agriculture. Some of the passengers disembarked, and others boarded for the final, brief leg to Belém, which lay less than 40 minutes’ flight to the north. By the time the doors closed, there were 54 people on board, including six crewmembers and 48 passengers. Many of the passengers were antsy — at that very moment, Brazil was playing a high-stakes football match against Chile to determine which country would play in the 1990 World Cup.

What should have been the route of the last leg of flight 254. (Google + own work)

As they sat on the apron at Marabá, Garcez and Zille configured their plane for the flight to Belém, adjusting their instruments and setting up the performance management system, or PMS. Since there was no designated airway between Marabá and Belém marked on their charts, Captain Garcez pulled out the printed flight plan produced by the airline to determine the precise magnetic heading to their destination. The computer-generated plan contained all the information they could need, including the heading to Belém, which was printed as “0270.” Captain Garcez therefore adjusted his Horizontal Situation Indicator, or HSI, to indicate a desired heading of 270 degrees, and First Officer Zille adjusted his own HSI to display the same value. With that out of the way, they set up the PMS, which would tell them the distance to their destination and remaining fuel endurance given the distance flown. Proper protocol held that they should also tune their instruments to pick up the signals from the non-directional beacon (NDB) at Marabá and the VOR radio beacon at Belém Airport, but Captain Garcez knew that visibility en route to Belém was good, making the airport easy to spot, so he didn’t bother.

A CGI image of flight 254 departing Marabá. (Mayday)

At 17:35 local time, flight 254 took off from Marabá, climbing away into the late afternoon sun. Because Marabá was an uncontrolled airport without a tower, there was no controller to watch them go, only a radio operator providing advisory information from a small building out of sight of the runway.

All seemed normal as flight 254 climbed to its cruising altitude of 29,000 feet, where it was to remain for only a few minutes before descending into Belém. In order to cross-check their position, First Officer Zille tried to tune into the Belém VOR beacon, but when he entered the frequency, the needle didn’t move — there was no signal from the beacon. So it goes, he surmised. Such problems were not uncommon in Brazil’s wild north.

Moments later, however, the situation became a little bit stranger when Zille attempted to call Belém air traffic control, only to receive no response from them either. Was something wrong with their radios? After repeatedly trying and failing to raise Belém using their VHF (very high frequency) radio, the crew switched to their HF (high frequency) radio, which has a longer range. At last, a voice appeared on the other end — but it was the voice of an Aeronautical Information Services officer, working out of a separate room in the control building, and not the controller, who didn’t have an HF radio. After some initial confusion, the AIS officer managed to relay flight 254’s descent request to the actual controller, who authorized them to descend to 20,000 feet.

With the help of this compass, can you figure out the mistake the pilots made? (Scouts South Africa)

By now their Performance Management System was showing that they had reached, and then passed, the optimal point to initiate their descent, so they immediately began to drop toward 20,000 feet as cleared. The controller, via the AIS officer, urged them to keep trying their VHF radio, but the crew succeeded only in raising other flights which were also en route to Belém, and not Belém itself.

A few minutes later, Flight 254 reached 20,000 feet and leveled off. Garcez and Zille searched the horizon for some sign of the city, but they could see nothing, only the vague contours of terrain beneath the lingering smoke, lit up by the setting sun. Minutes ticked by amid confused conversation with air traffic control. Something about the situation felt wrong, but no one could say what.

Still cruising at 20,000 feet, flight 254 reached the point where their PMS said they should be over Belém, but below them lay only a vast tract of smoke-shrouded rainforest. The distance to destination on their PMS ticked over into the negative: -1 miles, -2, -5, -10, -20. Still, they kept going, wondering if they had somehow entered the wrong distance, expecting Belém to appear at any moment, but it did not.

At thirty miles past the point where they should have reached the city, Captain Garcez finally acknowledged that it could not possibly lie ahead of them. In his opinion, they must have flown past Belém after failing to spot it amid the smoke, which meant that the city must be somewhere behind them. Captain Garcez started to turn back the way they came, and First Officer Zille informed air traffic control that they were turning around. Garcez, confident that they would find Belém this time, requested and received permission to descend further, to 4,000 feet. Once again, flight 254 began to drop, its pilots scouring the horizon for any sort of landmark.

Still unable to pick up a signal from the VOR radio beacon in Belém, First Officer Zille tried tuning in to a Belém-based commercial radio station called Radio Guajará, hoping that they could follow it to the city using their automatic direction finders, or ADFs. Zille managed to get a weak signal from the station, which was broadcasting the football match, but as a navigational aid it was too unreliable, and little useful information could be gleaned from it. He instead tried entering the frequency for another Belém radio station called Radio Liberal. Surprisingly, this one came through loud and clear, broadcasting a live Sunday religious service.

What the pilots may have seen as they approached the unidentified river. (Google)

Meanwhile, Captain Garcez scanned the terrain ahead using the plane’s on-board radar until he spotted what appeared to be a large river. Could this be the local branch of the Amazon? The ADF, tracking Radio Liberal, was pointing to the right, coincident with the direction of the river. That was enough for Captain Garcez — Belém must lie to the right. Descending through 10,000 feet, he made a right turn to follow the river, into the rapidly gathering darkness.

Flight 254 soon reached 4,000 feet, where it remained for some time as Garcez followed the twists and turns of the river, waiting in vain for the lights of Belém to appear around the next bend. The ADF kept indicating that they were on course toward the transmitter of Radio Liberal, but that didn’t make sense — if they had gone past Belém, turned around, and then followed a river to the right, they should have reached the city long ago. An hour passed in total darkness. Still, they saw nothing more than the interminable outline of the river on their radar, snaking through empty wilderness.

Where flight 254 actually flew… (Google + own work)

It was then, in the process of reviewing flight documents, that the pilots discovered that they had made an incredible error: although they had taken off with a heading of 270 degrees, the heading from Marabá to Belém was supposed to have been 027 degrees. They had flown to the west, not to the north. The reason they couldn’t detect the signal from the Belém VOR or contact Belém ATC on VHF radio was because they were never anywhere near the city, and the transmitters were out of range. And that meant that they were following the river to the south, not to the west, which in turn meant that this river was not a branch of the Amazon, but the Xingu. That left the pilots with two glaring questions: where were they, and what were they going to do about it?

Air traffic control was of no help, because neither Belém nor any other nearby airport was equipped with radar. And to make matters worse, they had now spent an hour and 14 minutes flying along at 4,000 feet, greedily burning fuel as the engines pushed the plane through the dense air at low altitude. If they didn’t figure out where they were soon, they would run out of fuel and crash. But they had flown for so long in the wrong direction, and made so many backtracks and turns, that even with the realization that they had initially flown to the west, Captain Garcez had only a vague idea of where they might be. Believing that they were probably somewhere on the L3 area navigation chart, he ordered Zille to look for this document in the stack of charts at the back of the cockpit. Zille dug around for a while, but failed to find it.

Garcez then switched to plan B: they would simply climb to a higher altitude and tune to the frequencies of navigational aids which he suspected were within range, namely the non-directional beacons (NDBs) at Marabá airport, where they took off, and at Carajás Airport, which lay further to the south. He and Zille then tuned one ADF to track Marabá on 370 kHz and the other to track Carajás on 320 kHz. The needles came to life, swinging around to point roughly toward the south-southeast. The crew told ATC that they were climbing to 8,500 feet and flying toward Carajás on a heading of 170 degrees. The Belém controller replied that Carajás had already closed for the night, but that someone would be sent out to the airfield to meet them. In the cockpit, the soft beeping of the NDBs broadcasting their identities in Morse code continued, unceasing.

Minutes passed, stretching out eternally. Cruising at 8,500 feet, the pilots watched their fuel quantity drop down toward zero, without seeing any sign of an airport amid the interminable blackness. Fear overcame them, followed not by panic, but resignation. They weren’t going to make it to an airport — they were going to crash, somewhere over the Amazon, and all that remained was to make peace with their god.

Captain Garcez picked up the PA and, for the first time, explained the situation to his passengers. There had been a malfunction of their navigation instruments, he said, lying through his teeth; and they were going to make a forced landing in the rainforest, as soon as the engines ran out of fuel. The response among the passengers was bipolar: some joined hands in a solemn prayer session, while others stormed the galley and wantonly distributed alcoholic beverages.

The left engine soon stopped as its fuel ran dry, followed a minute later by the right. The plane lost electrical power, leaving the pilots with only the tiny standby instruments on the center console. Outside the plane, the only light was the eerie glow of a forest fire in the distance.

Garcez and Zille lowered the flaps and raised the nose to extend their glide, for what little good it would do them. Their only hope was to impact the forest at a rate of descent low enough to allow for the possibility of survival. There was no way to choose a landing site, because the terrain below was as black as the void between the stars — there was nothing to distinguish whether it was flat or hilly, dry or wet. All they could do was hope, pray, and fly the airplane until the end.

The full course of flight 254, with the exact location where it went down. (Google + own work)

And then, with a rising series of thuds and bangs, the plane began to strike trees. Amazonian giants measuring 30 to 40 meters in height bludgeoned the fuselage and wings, clawing away chunks of metal one after another. Within seconds, the 737 sank into the woody canopy, and two huge trunks tore away both wings with a tremendous ­thud. The fuselage lurched almost to a stop as it slammed into the ground, sending a panicked and drunken passenger, who had gotten out of his seat to stand in the aisle, flying forward through the cockpit door. The floor twisted upward; seats dislodged and piled forward in the darkness, throwing passengers against one another amid the cacophony of rending metal. And then, just as suddenly as it began, the noise came to a stop. Varig flight 254 was down.

This CGI animation of flight 254’s forced landing appeared in Mayday season 14 episode 3: “Vanishing Act.”

Within moments of this sudden silence, the majority of the passengers and crew came to the shocking realization that they had survived the crash. One group of about eleven passengers, most of them suffering from only minor injuries, immediately opened one of the rear exit doors, jumped two meters down to the ground, and ran away into the jungle, fearing an explosion. They had apparently overlooked the fact that the plane no longer had any fuel on board, and therefore couldn’t explode.

The fuselage came to rest intact, leaning somewhat over on its right side. (Bureau of Aircraft Accidents Archives)

Captain Garcez also survived the crash with minor injuries, finding himself in a mostly intact cockpit alongside the body of the hapless standing passenger, and his unconscious copilot, who had hit his head on a metal support in his headrest. Flashlight in hand, Garcez entered the cabin to find that most of those who could escape had already done so, leaving behind dozens more who had become trapped in a massive tangle of dislodged seats toward the front of the plane. With the help of the other passengers and crew, he organized an effort to extract them from the wreckage, working to save as many as possible. It was clear, however, that several were beyond hope. At least eight people had died more or less immediately, including the passenger who was standing in the aisle, as well as another man whose chest was crushed by a suitcase which he insisted on carrying on his lap, while the rest had suffered fatal head injuries when their seats dislodged from the floor and slammed into the rows in front of them.

A woman and a child at the crash site. (G1 Globo)

As hours passed without any contact with the outside world, the survivors of flight 254 began to suspect that rescuers did not know where they were. Sometime that night, Captain Garcez recalled that the 737’s emergency locator transmitter, or ELT, was an outdated model designed to help searchers find the plane if it was lost at sea, and would only activate if immersed in water. Because they had crashed on land, it wasn’t broadcasting their position. Garcez attempted to activate it by placing it in a bucket with melted ice from the galley, but this was insufficient, so the survivors began urinating in the bucket to try to submerge it further. After a few hours, they confirmed that the strategy had worked when a passenger detected a signal from the ELT using their Walkman.

The survivors had no idea that at that point, searchers were still looking for the plane near Belém, and that a satellite data expert who could identify their ELT signal wouldn’t be called in until early on Monday morning, more than nine hours after the crash.

Aboard the crashed plane, meanwhile, supplies dwindled and tensions ran high. The mineral water and alcohol quickly ran out, as did the painkillers from the first aid kit, and the sandwiches were soaked in blood and couldn’t be eaten. And while the popular perception is that in a rainforest water is plentiful, this proved not to be the case, as there was no water anywhere nearby. In fact, the survivors’ thirst soon became so intense that fights broke out over the last remaining bottles.

The inside of the plane after the crash. (Bureau of Aircraft Accidents Archives)

Monday came and went with no sign of impending rescue. Inside the mangled fuselage, the most seriously injured passengers began to succumb, one after another. The death toll rose to ten, then eleven.

Salvation first came from within, not from without: more than 24 hours after the crash, a passenger came to Captain Garcez and identified himself as Afonso Saraiva, a 19-year-old unemployed prospector experienced in the ways of the forest. Using his wildland experience, Saraiva was able to lead the group to a clear stream not far from the plane, where he and other passengers filled bottles to bring back to the group. Others subsequently followed, some to bring back water, others simply to bathe — some of them in full bikinis.

As they did so, however, a plan was taking shape to search for some kind of civilization. On Tuesday morning, a party of four set out from the plane, hacking their way through the jungle in the best direction they could guess. Success met them surprisingly quickly: after covering just a few kilometers through the dense undergrowth, the land opened out into a pasture, and in the distance there was a man on horseback, herding livestock! It was the first civilization they had seen in nearly 48 hours. At last, they had reached the beginning of the end of their survival ordeal.

Survivors sit near the plane. (Bureau of Aircraft Accidents Archives)

The farm where the survivors found themselves was so remote that it didn’t even appear on maps, and its owners possessed no way to directly contact the authorities. Instead, the owners took one of the four survivors, Epaminondas Chaves, onward by car to another farm, where they knew a man who operated a ham radio. It was here that Chaves finally broadcast news of their plight to anyone who would listen, repeating his story over and over to whoever happened to reply to his transmissions. It took some time for authorities to get wind of the calls and even longer before they took them seriously–Chaves would later claim that search and rescue officials did not believe him until he had repeated his flight 254 ticket number “about eight hundred times.”

With the help of the survivors, rescuers were able to quickly zero in on the crash site, and by late afternoon on Tuesday the 5th of September, a small plane was dropping supplies to the survivors from the air. A helicopter with rescuers arrived soon after, but with night rapidly falling, there was only enough time to evacuate one survivor — a seriously injured woman who was lifted out on a stretcher, although she died in hospital soon after, becoming the crash’s twelfth and final victim. The remaining passengers and crew spent one more night in the airplane, although this time they did so with plenty of food and water, and in the company of rescuers trained in first aid. They were evacuated in a series of helicopter sorties on the morning of the 6th, with the last survivor finally leaving the site 63 hours after the crash.

A Brazilian newspaper announces the discovery of the survivors. (Jornal do Brasil)

At least as surprising as the discovery of the survivors was where they were found. Somehow, a plane which should have been on a 40-minute hop from Marabá to Belém had flown for more than three hours in completely the wrong direction, finally ending up in a remote area of Mato Grosso state near the town of São Jose de Xingu, more than 1,100 kilometers south of Belém and 800 kilometers south of Marabá. The scale of the navigational error defied rational explanation. How could a flight which was supposed to go north end up so far south of where it started? This would turn out to be a question so vexing that people still struggle to understand it today.

A soldier works at the crash site. (Aviation Brasil News)


In the immediate aftermath, the story of the search for the plane and the survival of 42 of its 54 passengers and crew captivated the Brazilian media, receiving wall-to-wall coverage at every major news network in the country. The survivors became instant celebrities, especially Captain Garcez, who was hailed as a hero for bringing the plane down safely in what was quite possibly the most difficult forced landing ever attempted by a large airliner. But even as First Officer Zille continued to recover in hospital from a serious head wound, investigators with CENIPA, Brazil’s air crash investigation agency, already knew that there was much more to the story than an instrument malfunction and a heroic crash-landing. The truth was that Captain Garcez had lied to his passengers and to ATC, because there was nothing wrong with his instruments, a fact revealed both by tests conducted on the plane’s intact avionics, and by the testimony of First Officer Zille, who reported that he ran similar checks in the air and found that everything was working correctly.

The cockpit voice recording provided little clarification, since it had only a 30-minute run time and had captured little more than the preparations for the emergency landing, without shedding much light on how the crew became lost in the first place. The flight data recorder, however revealed that flight 254 departed Marabá headed due west instead of north, flew for almost an hour, turned around, backtracked to the Xingu River, followed it south for another hour, then left the river and proceeded south-southeast on a straight line to nowhere until it ran out of fuel. This ridiculous flight path raised as many questions as it answered. And without recordings of cockpit conversations or transmissions on Belém’s HF radio, the events of the flight would have to be reconstructed based on whatever testimony the pilots’ union allowed Garcez and Zille to provide.

A recreation of what flight 254’s flight plan would have looked like. (Mayday)

Piece by piece, using a variety of sources, the CENIPA investigators managed to reconstruct where Garcez and Zille went wrong. The sequence of events began with the pre-flight preparations, and specifically the airline’s computerized flight plan. A few months before the accident, Varig had acquired several new airplanes which were equipped with navigation instruments capable of tracking magnetic heading to within a tenth of a degree. To accommodate this, the company began printing flight plans with route headings using four digits instead of three — thus 027 degrees became 027.0. This was displayed on the printed flight plans as 0270, without the decimal point. Despite the issuance of several crew bulletins related to flight plans in the months since the change, none of them specifically mentioned the switch from three to four digits, even though it would have been confusing to pilots on the 737–200, whose instruments accepted only three digits.

In practice, Varig pilots rarely used the headings on the flight plan for navigation, preferring to rely on their navigational charts. But a few of Varig’s routes, including Marabá to Belém, did not follow any designated airway displayed on the charts, and in these cases pilots would have relied on the flight plan to determine the exact heading to their destination. As a result, when Captain Garcez checked the flight plan for the heading to Belém, it was very likely the first time he had used the document for that purpose since the change to four digits. Lacking knowledge of the change, he read 0270 as 270 degrees, or due west, when in fact it meant 027.0 degrees, or north-northeast.

This was the view which greeted rescuers when they first arrived at the site. (G1 Globo)

Garcez dutifully entered 270 degrees into his HSI, somehow failing to realize that Belém lay to the north, not the west. Zille then entered the same heading on his own HSI, apparently copying his captain. The investigators believed he simply entered whatever Garcez had entered without cross-checking, while Zille would later contend that he did cross-check the flight plan, but made the same mistake independently. Regardless of which version is correct, the result was that flight 254 took off heading west, not north.

As absurd as it sounds, this meant that two trained Varig pilots — who had surely flown to Belém before — either did not know that Belém was north of Marabá, or did not know that 270 degrees was a westerly heading. If they had known both of these things, then a heading of 270 degrees to Belém should have felt instinctively wrong. And while many people have no innate sense of direction or ability to place themselves on a mental map, we should probably expect airline pilots to possess these skills, and why they did not is a question which has never been adequately answered.

Another view of flight the cockpit where it came to rest. (Bureau of Aircraft Accidents Archives)

The pilots could still have caught the mistake by tuning one VOR Receiver to the Belém VOR and an ADF to the Marabá NDB, ensuring that the plane remained somewhere in between them. And if they couldn’t pick up Belém, then they could have used the VOR in Tucuruí, which was closer. In the event, however, neither pilot attempted to tune in to the Belém VOR until they had already flown so far west that it was out of range. When they also failed to raise Belém ATC on short-range VHF radio, it became clear that something was wrong, but neither pilot considered the possibility that they were not where they thought they were. Instead, Captain Garcez seemed to be relying on his performance management system, which simply tracked their progress in terms of miles traveled, regardless of which direction they were flying.

Even after they had covered the full distance to Belém plus thirty miles, the pilots still did not realize what had happened. Garcez turned around and tried to backtrack, but failed to find Belém again, because it wasn’t there. It would still have been possible to retrace their steps and go back to Marabá, but either out of arrogance or naïveté, they did not.

At this point, First Officer Zille tuned into what he thought were Radio Guajará and Radio Liberal, two Belém-based commercial radio stations transmitting on 1330 and 1270 kHz respectively. But investigators found that they had actually picked up Radio Clube de Goiânia and Radio Brasil Central, two stations broadcasting on similar frequencies from the city of Goiânia, hundreds of kilometers to the south. Both the stations in Belém and those in Goiânia were theoretically out of range at the time, but flight tests showed that the broadcasts from Goiânia could be picked up intermittently in the area west of Marabá due to reflection of the signals off the ionosphere. Because these were commercial stations which didn’t broadcast information identifying the signal source, there was no way for the crew to verify that they came from Belém, but Captain Garcez followed them anyway.

The back of the plane, where several passengers escaped immediately after the crash. (Bureau of Aircraft Accidents Archives)

Garcez then spent the next hour flying at 4,000 feet down the Xingu River, following the radio broadcasts from Goiânia, apparently believing that he was following the Amazon to Belém. He must have known they were flying south, but again, some basic understanding of geography was obviously lacking, because if they were flying south toward Belém then they would be over the ocean, but they were over land.

It wasn’t until this point that the pilots realized their original heading error, although the CENIPA investigators wrote that they still suspected some kind of instrument failure. Once this mistake was discovered, prudence called upon Garcez to climb as high as possible, radio for help, and try to triangulate where they were based on nearby navigational aids. Instead, Garcez told no one of the nature of their predicament, climbed only to 8,500 feet, and tried to find his way to Marabá or Carajás, without knowing whether those airports were even in range. Climbing higher would have given them a better line of sight, but they did not.

When Zille and Garcez tuned their ADFs to the frequencies for the NDBs at Marabá and Carajás, they thought they could simply follow them until they arrived at one of these airports. But had they listened closely to the Morse code broadcasts transmitting the identity of these beacons, they would have realized that they had actually tuned in to a different pair of navigational aids which broadcast on the same frequencies. These beacons were located in Goiânia and Barra do Garças, both far to the south of their position. Like the commercial radio stations before them, these signals were being reflected off the ionosphere, extending their range significantly.

Another view of the branch-covered tail section. (UaiSôMochilando)

For whatever reason, neither pilot listened closely enough to the Morse code broadcasts to positively ascertain the identities of the two beacons. By this point they were desperate, anxious, and scared, and wanted only to reach Marabá or Carajás as quickly as possible. Any information which suggested that they had not solved the problem and were still headed the wrong way was simply tuned out, and the pilots interpreted the Morse code broadcasts to be whatever they desired. A deadly cocktail of confirmation bias and denial had thus sealed their fate.

Had First Officer Zille managed to locate the L3 area navigational chart, however, they might have realized that there was still one airport within range. During the final 40 minutes of the flight, they passed within 100 nautical miles of a large military base in Cachimbo, at a point when they still had 105 nautical miles of fuel. But without access to the L3 chart, the pilots wouldn’t have known to look for this airport. In a tragic twist, however, the missing chart was found in the wreckage of the airplane, proving it had been there all along. Why Zille failed to find it was never determined.

Rescuers remove a body from the crash site. (Celso Bruno)

In the end, CENIPA couldn’t even praise the pilots’ emergency landing, which they felt was successful in spite of, not because of, the actions of the pilots. The investigators questioned why the pilots decided to glide to a forced landing, when they could have ensured a shallower rate of descent on impact by descending earlier and letting the engines flame out a couple hundred feet above the ground. Furthermore, they made configuration errors following the dual engine flameout which nearly caused a total loss of hydraulic pressure. This proved to be the final, crushing blow to the myth of the heroic Captain Garcez.

But perhaps the harshest critic of Garcez was not a CENIPA investigator, but his own First Officer, Nilson Zille. While Garcez does not speak to the media, except for brief statements denying any responsibility for the crash, since 2019 Zille has granted interviews, given talks, and even co-authored a book in which he has added considerably to CENIPA’s account of events. In his opinion, the accident was caused not by tragic mistakes and misunderstandings, but by simple hubris and arrogance, those most insidious of human failings.

According to Zille, Garcez didn’t conduct a proper descent briefing or carry out any required cross-checks during the flight. Then, when they first contacted air traffic control, they were told to intercept the 240-degree radial of the Belém VOR — that is, to approach the VOR from the southwest, the direction of Marabá. But they were flying on heading 270, or due west, so if they were in fact headed for Belém, then they should logically be arriving from the east, on the 090 radial. Zille claimed that it was at this point that Garcez realized he had screwed up, although he didn’t yet understand how. But instead of trying to find the cause of the problem, he simply told ATC that they had suffered an instrument malfunction. Zille knew this was a lie because he could see all the same instruments as his captain, and there was no indication that anything was wrong with any of them.

A poster for the talk given by Nilson Zille in 2019. (Escola de Aviação Congonhas

According to Zille’s account of events, after turning around at 30 miles past the endpoint of the PMS, Zille suggested that they just go back to Marabá, but Garcez refused, apparently worried that he would be fired if he didn’t manage to get the passengers to Belém. By now some passengers were aware that something was wrong, and one of them offered to come up to the cockpit to help the pilots figure out where they were, but Zille says both he and Garcez turned him down.

Soon, the river came into view, and Zille pointed out that it didn’t look like any river near Belém that was shown on their charts, to which Garcez allegedly replied, “These [charts] are garbage, the American Jeppesen charts are the actual good ones.” Garcez believed that Belém lay down the river to the right, and while Zille disagreed at first, he was convinced when he tuned in to the radio station and the ADF needle pointed to the right as well. But his newfound confidence was short-lived. Zille says that after 30 to 35 minutes flying south along the Xingu River, he told Garcez that they should have seen Belém by now, and in any case they were flying south, while in his opinion Belém lay to the north. Garcez then became angry, belittling Zille in an expletive-laden rant. Besides, he said, the ADF needles pointed south, so Belém must be that way. At that point, Zille claims, he became little more than a glorified passenger, as Garcez no longer listened to anything he had to say.

Nilson Zille poses with his book about the accident. (ASA)

Garcez, totally preoccupied with finding Belém instead of figuring out where they actually were, spent the next hour wandering around at 4,000 feet wasting all their fuel. It wasn’t until almost three hours into the flight that Zille finally identified the mistake they had made, but when he tried to explain it to his captain, Garcez simply shushed him and pointed at the cockpit voice recorder microphone.

Nevertheless, Zille claims he suggested that they climb to 37,000 feet and have a look around, but that Garcez responded with a tepid ascent to 8,500 feet, insisting that they were near Carajás and would see the airport at any moment. When it became clear that this would not happen, Zille says Garcez fell into deep despair, telling Zille that he would “meet [him] on the other side.” The subsequent emergency landing, according to his account, was flown not by Garcez — who had completely frozen up — but by Zille himself. If true, his inexperience might explain the serious errors in its conduct. In any case, they survived the landing, and Garcez tried to distinguish himself by helping the wounded — except for Zille. Zille claims that Garcez left him in the cockpit, later to be rescued by a female passenger, who had been told by Garcez that Zille was dead. Needless to say, he was not.

Zille freely acknowledges that he made mistakes, and that perhaps he could have done more to prevent the accident. But he also says that in 1989, Varig had a steeply hierarchical cockpit culture, and captains like Garcez often refused to accept their first officers’ input. In his opinion, trying to push harder would have been more likely to cause a physical altercation than to solve the problem.

During the game, which took place as flight 254 was in the air, a fan threw a flare at the Chilean goalkeeper, who pretended it hit him, causing Chile to abandon the game. The match was so dramatic that it was not hard to believe the pilots could have been sucked in too. (El Gráfico)

There is a popular theory which says that the pilots failed to recognize their error because they were listening to the Brazil-Chile football match on the radio. Although the possibility cannot be definitively ruled out, Zille took the time to rebut this too. According to him, before departure a passenger asked one of the flight attendants whether the match had started; the flight attendant then asked the pilots, who in turn asked the Marabá AIS officer. The response was then relayed all the way back to the passenger, who later assumed that the answer came from the pilots themselves. Zille says that this passenger was responsible for the theory, but absent any recording from this part of the flight, it’s impossible to know whether he’s telling the truth.

In the end, Zille’s account can hardly be considered unbiased, but it is the only first-hand account available. Garcez has not told his side of the story, stating only that he was not at fault and that his instruments malfunctioned. Despite its tendency toward self-aggrandizement, Zille’s story seems believable in comparison.

By the time this picture was taken, it appears the jungle was already starting to reclaim the fuselage. (Bureau of Aircraft Accidents Archives)

Unfortunately, the very public rift between the two pilots was hardly the only ugly consequence of the crash of Varig flight 254. During the search for the plane, a mob of relatives broke into the Varig headquarters, ransacked an office, and attempted to assault Varig president Hélio Smidt. Smidt subsequently drew outrage when he told the press that the people who died in the crash had gotten too drunk and decided not to wear seatbelts, apparently ignoring the fact that several of the dead were children, and that most were, in fact, strapped in for the landing.

According to Zille, Varig was reluctant to learn anything from the accident, and initially refused CENIPA’s recommendation to return to the original three-figure heading format. He says that this change was only made after another crew made the same mistake on a flight to Cayenne in French Guiana, causing them to fly a heading of 060 instead of 006. Corroborating accounts of this incident, if they exist, were not found during research for this article.

As a result of the accident, both Garcez and Zille were charged and convicted of negligence, receiving a sentence of four years in prison. An appeal later reduced this to community service, although Garcez also lost his pilot’s license. Zille nominally kept his, but he says he might as well have lost it, because few airlines, if any, were willing to hire him.

Another newspaper headline from the aftermath of the accident. (Folha de São Paulo)

Trying to determine what lessons to draw from this utterly bizarre tale may be an exercise in futility. It certainly goes without saying that every pilot ought to know where their destination is located and how to interpret a compass heading. Zille has gone to great lengths to show how easy it was to confuse “0270” for 270 degrees, and certainly no one denies that the printout was highly misleading, but neither he nor anyone else can explain why this interpretation wasn’t immediately discarded as nonsensical. How can you fly west from Marabá to Belém? Any pilot responsible for that route should know that you can’t. Had no lives been lost, the story would have been rather amusing, but instead twelve people died because of an ignorance so fundamental that it defies rational explanation. This conundrum remains the greatest unanswered question about flight 254, and it will probably never be answered, except by resigning ourselves to the conclusion that Garcez and Zille were both so spatially impaired that they entered a ridiculous course, and, trapped by their own unresponsiveness to critical self-examination, blithely followed it to their common doom.


Join the discussion of this article on Reddit!

Visit r/admiralcloudberg to read and discuss over 220 similar articles.

You can also support me on Patreon.



Admiral Cloudberg

Kyra Dempsey, analyzer of plane crashes. @Admiral_Cloudberg on Reddit, @KyraCloudy on Twitter and Bluesky. Email inquires -> kyracloudy97@gmail.com.