I don’t think I knew about this accident from the time (1989), partly because it transpired entirely in Brazil—Marabá to Belém. As I watched the Smithsonian channel’s rendition of it, I was puzzled by aspects it left out, some of which I was able to piece together from online sources, but, as it was totally Brazilian, there’s no NTSB report. There is, however, an Aviation Safety Network write up which gives some particulars and a precis of events
My dissents are two-fold—one is more pilot centric, the other leans more toward the ATC side. To set this up, the distance between the two airports is about 280 miles. Almost any flight in Brazil must include the phrase “Amazon rain forest”, and this one in particular was well away from any population centers. They took off into a sunset and the flight transitioned into darkness.
First, the Captain set 272 in the HSI, not in itself a huge mistake, but it was portrayed as such. More importantly, though, after departure (not sure which runway, although that isn’t really relevant) the crew flew a course of 270° for forty minutes, approximately the expected time enroute to Belém. I cannot imagine any kind of pilot, much less Air Transport Rated, whose situational awareness was so lax that they didn’t have the remotest notion of where Belém was in relation to Marabá. That’s cross country planning 101, and is covered in the first twenty hours of basic flight training.
Then these aviation geniuses finally decided, “oops, maybe we should backtrack”, which they did, for another twenty or so minutes, basically looking for something helpful. Finally they spotted a river, which they assumed was the Amazon, and turned right to follow it to Belém, which lies in the Delta. Eventually, flying on a heading of ≈165° (away from Belém), they ran out of fuel and crash landed in the jungle. The mind boggles.
Complications, which were not wholly addressed by the narrative, include radar versus non-radar environment, turns to courses which could not have any relevance to their projected flight path, and communications. They were never able to contact the tower at Belém on VHF, although they did raise him on HF.
In the investigation and in the denouement, much was made of a company flight plan format which had been implemented while the captain had been on leave. In it, initial courses on departure were given in four digits, no decimal points. Thus, their flight plan showed 0272. The investigators concluded that since 027.2° was clearly intended, the pilots (Captain—the First Officer was doing the walk around when the HSIs were set) inerpreted it as 272°. I take great issue with that interpretation, as leading zeros are never used in compass headings except the first 99. It’s literally impossible to interpret the format so that 0272 was anything other than 027.2°
From the ATC standpoint, virtually no information was provided as to the allocation of airspace in the region. 280 miles is roughly the distance from DSM to SBN, a segment with which I’m highly familiar. They got as high as FL290, which means there may have been a high altitude (FL240 and above in the U.S.) stratum of control involved. Doesn’t matter if there was or wasn’t, but I am interested in what radar facilities might have been serving the region, and what A/G (air ground) radio facilities might be in place.
I inferred from the narrative that Belém had a non-radar approach control in its tower, but I don’t know what Marabá might have. It, too, isn’t that important as IFR services and separation could easily be provided between the two airports with no radar whatsoever. ATC 101. We did it for years, we still train for it, and it’s still supposed to be our fall back process in the event of radar failure.
More importantly, whatever services were at Marabá, any ATC clearance to destination would have included instructions to transition to their own navigation once they’d departed. A 270° for forty minutes could not have gone uncorrected by ATC, even non-radar.
Implication was made that a national football match was in progress and that trying to keep tabs on it may have caused inattention in the cockpit. This is the country that gave us Pelé, after all. But I don’t find that compelling. You just can’t get past flying perpendicular to your desired course for forty minutes in a jet—twice, and then away from it once. It didn’t seem like they worked very hard at their job.
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