All language subtitles for Mayday - S02E05 - Lost (Crash On The Mountain) WEBDL-1080p_track3_[eng]

(alarm sounding)

- We just lost 1 and 2.

(narrator): All four engines
shut down on a jet headed
straight for a U.S. suburb.

- It takes a few things
to make an engine run,
and one of them is fuel.

- Everyone, we're about
to evacuate the plane.
Remain calm.

(narrator): In Japan,
a plane catches fire

with all 165 passengers and crew
still on board.

- The only time you have
too much fuel on board
the aircraft

is when you're on fire.

- We just lost an engine!

- Hang on.

(narrator): And the crew
of a 737 are forced

to make a crash landing
in the Amazon jungle.

- Something is very, very,
very wrong here.

(narrator): Three mysterious
accidents send investigators
hunting for clues.

Is it possible these tragedies
all share the same cause?

- Mayday, mayday!

- It's going up!

(indistinct radio chatter)

(narrator):
United Airlines Flight 173

is 22 miles away from Portland
International Airport.

The 189 passengers on board
are returning home
after the holidays.

- United 173 would like
clearance for an approach
into 28 left now.

(narrator):
Captain Malburn McBroom,
a Second World War veteran,

is one of United's
most experienced pilots.

First Officer Rod Beebe
has more than 5,000 hours'
flying experience.

Flight Engineer
Forrest Mendenhall
is the third crew member.

- Okay.

(narrator): He's tasked
with monitoring
the DC-8's engines.

The flight began
in New York City
with a stopover in Denver.

- United 173 heavy.

Okay, roll out, heading...

010 to runway 28 left.

(narrator): Air-traffic
controller Ed Kingrey

clears flight 173 to land.

Suddenly, an alarm sounds
in the cockpit.

- We're losing an engine.
(beeping)

It's flamed out.

- You're gonna lose #3
in a minute, too.

(narrator):
Two of the plane's four engines
have just shut down.

- You gotta keep 'em running,
Frosty.
- Yes, sir.

(narrator):
The engineer struggles to keep
the last two engines running.

- How far do you show us
from the field?

- I'd call it, uh...
I told him it's 18 flying miles,

which would include
the base leg to the final,

and then the turn to final
to the end of the runway.

(alarm sounding)
(automation): Airspeed low.

- We just lost 1 and 2.

(narrator): Flight 173
has now lost all four engines.

With the aircraft dropping
by more than 3,000 feet
a minute,

Captain McBroom makes
a horrifying calculation.

- We can't make it.

- We can't make anything.

- Okay, declare a mayday.

- Portland Tower,
United 173 heavy. Mayday.
The engines are flaming out.

(narrator): McBroom needs
to find a safe place
to put the aircraft down

and try to save the lives
of all on board.

- I could see him coming in
from the south,

his navigational lights
flashing.

You could tell he was quite low.

(passengers screaming)

(screaming)

I saw the bright flash
out there,

and, uh,
and knew he had gone down.

(narrator): The DC-8 has
crash-landed in a wooded suburb
in Portland, Oregon.

(dog barking)
Eight passengers and two members
of the crew are dead.

Incredibly, 179 people survive.

(news): A United Airlines plane
crashed five miles
southeast of Portland Airport,

in a residential area.

Two homes were hit,
one disintegrated.

(narrator): The next morning,

investigators from the National
Transportation Safety Board
are on the scene.

One of the team members
is Human Factors Specialist
Alan Diehl.

- When I saw how close he'd come
to apartment complexes,

I realized this could've been
one of the worst accidents
in history.

(narrator): Investigators hope
survivors can provide
some insight

into what brought this jet down.

- When did you first notice
something out of the ordinary?

(narrator):
They learn from the passengers
that an hour before the crash,

the captain
made an announcement.

- Ladies and gentlemen,
this is your captain speaking.

(narrator):
The crew were having trouble
with the landing gear.

(Captain): We're not sure
whether or not it's working
correctly.

We'll be running
a few routine checks.

(narrator): But something
isn't making sense to Diehl.

- How does a landing-gear
problem bring down a plane?

(narrator): At the crash site,
the plane's flight recorders
are recovered.

They're sent for analysis
at the National Transportation
Safety Board headquarters

in Washington.

While they wait
for the flight data,

investigators continue
to speak to witnesses,

including Ed Kingrey,

the controller who handled
Flight 173's approach.

- I cleared 'em for an approach
to runway 28.

I was about to hand 'em off
to the tower controller.

- Uh, negative.
We'll stay with you.

We've got a gear problem.
We'll let you know.

- He basically said
he'd stay with me, that...

he was having some kind of, uh,
unsafe-gear indication.

(narrator): Captain McBroom
wanted time to troubleshoot
the gear problem.

So Kingrey cleared Flight 173
to fly a holding pattern
south of the airport,

over the Portland suburbs.

- A holding pattern
would basically give him...

his own airspace there
to do whatever he had to do.

(narrator):
But Flight 173 circled Portland
for an unusually long time.

- They continued circling
for about an hour.

(narrator): The pilots then made
a shocking call
to the Portland Tower.

- I recall hearing...

the captain tell the tower
they're losing engines.

There was no indication
to me,

uh... the gravity
of the situation.

(narrator): What happened
during that hour of circling

that turned
a landing-gear malfunction...

- We've got a gear problem.
We'll let you know.

(narrator):
...into a catastrophic
engine failure?

- The engines are flaming out.
We're going down.

We're not gonna be able
to make it to the airport.

- I was clearly very interested
in, you know,

how a highly experienced captain
could, uh, fly around
for over an hour,

in sight of the airport,
in good weather,

and not put this airplane
on the ground safely.

(narrator): NTSB investigator
Dennis Grossi joins the effort
to find out what went wrong.

- I was assigned to be the...

aircraft performance engineer
for this accident.

Okay, let's go.

(narrator):
If there was a malfunction,

he hopes the cockpit
voice recorder picked up
the pilots discussing it.

- Ladies and gentlemen,
this is your captain speaking.

(narrator): The recording begins
30 minutes before the crash

as the pilots circle
over Portland.

- ...because I only got this
thing to shine down there.

(narrator):
They hear the flight engineer
leave the cockpit

to troubleshoot
the landing-gear problem.
(alarm sounding)

When the landing gear
is lowered,

a small rod pops up in the wing,

providing visual confirmation
that the gear is in place.

- The flight engineer
would be asked by the captain
to go back and check

the mechanical indicators
for the position
of the landing gear.

- Excuse me.
Can I look out the window here?

- And he could look over,
and there are tabs that actually
come up and go down,

and he could see if the gear
was extended and locked.

- How's that main gear
back there?

- Uh, both appear to be down
and locked.

(narrator):
Despite his engineer's report,

Captain McBroom
still sounds concerned.
(alarm sounding)

- There's one check we missed.

Checking the gear warning horn.

- Uh-huh. Right.

- Right.
- Right.

- Normally, when we see
these problems of a gear light
not coming on,

it's a light bulb or some
minor piece of circuitry.

(narrator): It appears
that a minor electrical problem

became a major distraction
for Captain McBroom.

But it still doesn't explain
why all four engines were out.

Then investigators make
a shocking discovery.

- Losing an engine.
It's flamed out.

- Why?

- Fuel.
(captain sighing)

(narrator):
The cockpit voice recorder
from United Flight 173 reveals

that the captain is unaware
that his plane
is running out of fuel.

- He was asking
what was causing that,

and he got a very adamant answer
saying: fuel.

- Fuel.
- As if to say:

We've been trying to tell you
about this all along.

- Number 2 is empty.

- You're gonna lose 3
in a minute, too.

(narrator): One by one,
fuel starvation shuts down
all the engines,

leaving the DC-8
without any power.

- Okay, declare a mayday.

- How could an experienced crew
lose track of how much fuel
they had on board,

and in fact run out of fuel

when they were in view
of the airport?

(narrator): Captain McBroom
may be the only one
who can provide answers.

He's in hospital
recovering from injury,

but well enough
to speak to investigators.

(alarm sounding)

- I recall...

seeing #1 and #2 warning lights
come on,

but I...

I knew we had fuel.

- He was still convinced
that somehow,

the fuel had either leaked out
of the tanks,

or the fuel burn was too high,
or the gauges were wrong.

(narrator): Investigators wonder
if the fuel gauges
were malfunctioning

and confusing the pilots.

To find out, investigators
study the transcript
of the cockpit voice recorder,

focusing on the pilots'
discussion of fuel levels.

- The crew discussed
how much fuel do we have.
We have 5,000 pounds.

You take the data
and apply the time factor to it,

and you can figure out
how much fuel
they should've had remaining.

- Five thousand.
That's exactly right.

(narrator): The team discovers
there's nothing wrong
with the gauges.

Flight 173's fuel system
was working exactly
as it should.

With mechanical failure
ruled out,

the team now explores
the human factors,

specifically Captain McBroom's
behaviour.

- How much fuel you got now?
- Four. Four.

(narrator):
Investigators play back
the cockpit voice recorder

to study his performance.

- How much fuel you got now?

(narrator): They hear something
alarming in the conversation.
(alarm sounding)

- How much fuel we got now?
- Four. Four, uh, thousand,
in each, pounds.

- Both the first officer
and the second officer...

...were acutely aware
of the fuel status.

(narrator): His crewmates tried
more than once to alert him
to the fuel situation.

But McBroom is focused
on the broken landing gear.

- There's one check we missed.

Checking the gear warning horn.

- Uh-huh. Right.

- Right.
- Right.

So how do we do that?

- Flying with a very senior
captain,

it would be very difficult
to challenge that captain
in those days, uh,

about something like fuel.

- The captain was so focused
on the gear collapsing
that he lost the big picture.

- They lost sight
of the real emergency,
which was the lack of fuel.

(narrator):
Captain McBroom's obsession
with the landing gear,

along with his crewmates'
failure to speak up,

caused the plane to run out
of fuel and crash
in the Portland suburb.

- After this accident,
the National Transportation
Safety Board

said flight crew members
need to be better trained
to communicate

when they have
safety-of-flight issues.

(narrator): In a move
that has a lasting impact
on airline safety,

the Federal Aviation Authority
adopts a training system
developed by NASA,

known as Cockpit Resource
Management, or CRM.

- It teaches captains
to listen better,

and it teaches the other members
on the flight deck
to be respectfully assertive.

(narrator):
If the crew of Flight 173
had received CRM training,

they might have insisted
that Captain McBroom
land immediately.

- Not enough.
Fifteen minutes is really gonna
run us low on fuel here.

(narrator): Instead,
they expected their captain
to make the right decision.

- Had it not been
for this investigation,

I'm pretty sure
that Crew Resource Management
would have taken place,

but at some point in the future,

and very likely other aircraft
would've crashed in the interim.

(narrator): In 2007,

a terrifying explosion
reminds investigators

that catastrophic fuel failures
don't just happen in the air.

(narrator):
China Airlines Flight 120
is on final approach for landing

in Okinawa, Japan.

(chiming)
(captain): Ladies and gentlemen,

we're about to begin our descent
into Okinawa Naha Airport.

Please give the flight
attendants your full cooperation

as they prepare the cabin
for landing.

(narrator): The captain
is 47-year-old Yu Chien-Kou.

- What's the weather
for approach?

- Cloud ceiling is 8,000 feet.
Winds at eight knots.

(narrator): The first officer
is 26-year-old Tseng Ta-wei.

The pilots have more
than 8,500 hours of flight
experience between them.

This morning,
there are 157 passengers
and eight crew on board.

- Please put your tray up
and fasten your seatbelt.

(narrator): The pilots
reconfigure their plane

as they slow down
and descend for landing.

- Let's go to flaps 25.

- Flaps 25.

(narrator): They deploy flaps
from the wings' back edge,

along with slats
from the front edge.

These devices keep the plane
airborne at lower speeds.

(automation): 30, 20, 10.

(narrator):
It's a textbook landing.

- Flaps in.

(narrator): All that's left
for the China Airlines pilots
is to park the plane.

- Engine start levers.

- Engine start levers cut off.

- Seatbelts.
- Seatbelts off.

(narrator):
Then one passenger notices
that something's not right.

(Speaking Japanese)

(alarm sounding)
- Hey, what is this?

- What's happening?

(narrator):
Just when they thought
they were safely parked...

- Cockpit, ground.
Number 2 engine fire.

(narrator):
...a radio call alerts them
to a fire in the right engine.

- Dynasty 120,
we are calling a fire truck.
Remain... Stand by.

(shouting in Japanese)

- Cabin crew,
prepare for evacuation.

Prepare for evacuation.

(narrator): Within minutes,
the fire engulfs both wings.

- No pushing, no pushing.

(narrator): Flight attendants
work to evacuate the passengers
as quickly as possible.

The plane could explode
at any moment.

- Captain, all passengers
are evacuated.
You're the last ones.

(coughing)

(narrator):
But it may be too late
for the pilots.

Thick smoke is consuming
the cabin,

so they will have to escape
through a small cockpit window.

- You first.
- Yes, sir.

(people screaming)
(man): Oh! Whoa!

(narrator): Incredibly,
both pilots evacuate
just in time.

All 165 people on board
escape unharmed.

- I've never heard
of any evacuation
where somebody wasn't hurt.

To get this many people off
in such a dire circumstance

in a very short period of time
with no injuries is miraculous.

- It's highly unusual
for an aircraft to catch fire
at that phase of flight,

so, uh, that sparked
a great deal of interest.

(indistinct radio chatter)

(narrator):
A team of international
air-crash investigators

are immediately called in.

They need to find the cause
before there's another
deadly explosion.

Across the globe,

there are more than 5,000
Boeing 737s in service.

- There's a 737 taking off
and landing

every three or four seconds
in the world.

(narrator):
Knowing countless passengers
could be at risk,

investigators race
to figure out how an airliner
that landed safely

suddenly burst into flames.

- Okay, let's get to work!

The challenge
for the investigator is...

most of the evidence
will be destroyed by the fire.

(narrator):
While recovery workers collect
the scorched wreckage,

the team begins
interviewing eyewitnesses.

- What did you see?

(narrator): A ground worker
who saw the explosion
provides a critical detail.

- The ramp worker
on the right side
of the aircraft

said very distinctly
that he saw a liquid

running down the leading edge
of the right wing
before the fire broke out.

- Thanks.

(narrator): Fluid leaking
from this part of the wing
of the aircraft

can only be one thing:

Jet fuel.

The Boeing 737 holds
4,390 gallons of fuel,

much of it in tanks
located inside the plane's
two massive wings.

- When we figured out
that an actual fuel leak
had occurred,

it was a breakthrough,
a true breakthrough
in the investigation.

- We know the fuel was leaking,
but from where?

(narrator): Investigators
examine what remains
of the 737's fuel tanks.

The tanks are made
from aluminum alloy
and should never crack or leak.

They use a small camera
called a borescope

to see inside
the right fuel tank.

What it reveals
changes the course
of the entire investigation.

- Whoa. Would you look at that?

(narrator): While examining
the right fuel tank
of China Airlines Flight 120,

investigators find a bolt
lodged in the side of the tank.

- All of a sudden,
clear as a bell,

we saw this bolt sticking out
of the fuel tank itself.

(narrator):
The bolt has ruptured the tank,

right where the ground worker
spotted leaking fuel.

- It's hard to describe
how significant this was.

I mean, this was the core
of the investigation.

(narrator): But where did
the bolt come from?

- Okay. Got it.

(narrator): Investigators
compare the piece to schematics
of the 737 wing structure

to figure out
exactly what it is.

They soon get their answer.

- A downstop assembly.

(narrator):
The downstop assembly

is part of the slat mechanism
on the wing's leading edge.

- Let's go to flaps 25.

- Flaps 25.

(narrator): Pilots extend flaps
and slats during every takeoff
and landing.

The downstop is fixed
to the end of a track
that slides back and forth.

The device prevents the slats
from moving too far forward.

- We had the assembly.
We knew it punctured the tank.

Our next step was trying
to figure out how this could
possibly have occurred.

(narrator): When comparing
the downstop assembly
from Flight 120

to Boeing schematics...

...the team uncovers
a vital clue.

- We decided to count parts,

and lo and behold,
a washer was missing.

(narrator):
There's supposed to be a washer
right behind the nut.

- Where is it?

(narrator): Could a single
missing washer have played
a role in the accident?

- Alright. Now let's test it
without a washer.

(narrator): The team experiment
with the suspicious bolt
from Flight 120

to see how it performs
without the washer.

They make a stunning discovery.

The small washer
is the only thing preventing

the unit from falling out
of its mount.

- Without the washer...
it fails.

(narrator): Investigators need
to find out how the part
could've disappeared.

- We went to China Airlines

to ask them to demonstrate
how they do...
the maintenance work.

- Sometimes maintenance records
don't tell you the true story.

(narrator): They learn a repair
was ordered on the downstop
a few weeks before the accident.

A mechanic demonstrates
how he performed the repair.

- After applying glue...
you put the bolt into place.

(narrator): But reaching
the downstop's location
proves challenging.

- You can imagine
that you're under the wing
and you cannot see it.

- Sorry. I just dropped it.

Don't worry.
It's easy to pick up again.

(narrator): It's an eye-opening
demonstration.

- It's not very easy for them
to confirm

they finished their job
and everything is in order
there.

(narrator):
Investigators believe the washer
must've fallen off

during the maintenance procedure
in Taiwan.

The sequence of events that led
to the devastating fuel fire
in Okinawa

is finally clear.

Six weeks after the failed
repair of a downstop...

- Please give the flight
attendants your full cooperation

as they prepare the cabin
for landing.

(narrator):
A descent into Okinawa
requires the pilots

to deploy the flaps and slats
as usual.

Inside one of the track
assemblies on the right wing,

the loosened bolt
without a washer
is just barely holding on.

Touchdown is enough of a jolt
to finally knock it
out of its track.

- Flaps up.

(narrator):
The unsuspecting crew soon
retracts the flaps and slats.

The plane's powerful hydraulics
move the slat track
back into place.

But now the downstop bolt
is in the way.

The track pushes it to the back,

puncturing
the right-wing fuel tank

and causing thousands
of litres of fuel to leak.

- After-landing checklist.

(narrator): Once the pilots park
and shut down the engines...

...the leaking fuel
starts dripping directly onto
the scorching-hot tail pipe,

igniting on contact.

In the wake
of the China Airlines explosion,

aviation authorities
around the world

order the inspection
of the entire fleet of 737s.

In the U.S. alone,

21 planes are found
to have the same defect,

all of them at risk
of a catastrophic fuel leak
and fire.

Boeing takes immediate action.

It redesigns
the downstop mechanism

and ensures
that the improved part
is installed

on each and every plane.

- In today's aviation,
the failure of any kind
of component part,

especially as it relates
to a fuel system,
is a rare event.

You stand a better chance
of survival

if you have a catastrophic event
on the ground.

But as the airplane goes up,
so does the risk level.

(automation): Terrain. Terrain.
(narrator): In Brazil,

investigators uncover
another fatal problem

when a disastrous fuel failure
brings down a plane
in the Amazon jungle.

(narrator):
Brazil in the late 1980s
is a country in transition.

Developing cities
are scattered throughout
the dense Amazon rainforest.

In Marabá,
the crew of Varig Flight 254
is preparing for takeoff.

- Exterior check complete.

(narrator):
There are 48 passengers
on board.

Flight 254
is an hour-long flight
from the mining town of Marabá

to Belém, near the mouth
of the Amazon River.

The crew dials in
a compass heading to guide them
to their destination.

- Here we go.

(narrator): Captain Cézar Garcez
is flying the airplane
tonight,

while First Officer Nilson Zille
monitors the instruments.

- V1.

Rotate.

(narrator):
The Boeing 737 steadily climbs
to cruising altitude.

After 23 minutes,
the flight computer
tells the captain

that they're getting close
to Belém.

- Looks like we're nearly there.
- Mm.

Belém Tower, Varig 254,
requesting descent.

Belém Tower, Varig 254.

- Belém Tower, do you read?

(narrator): Strangely,
they get no response
from the tower.

- Let me try.
Belém Tower, Varig 254.

- Hmm. That's funny.

- What?

- We're not picking up
the beacon either.

(narrator):
Airports are equipped

with Very High Frequency
Omnidirectional Range beacons,
or VOR beacons.

Their signal guides
incoming aircraft
to the runway.

- I'll call the tower on HF.

(narrator): The captain switches
his radio to high frequency
and tries making contact again.

- Belém Tower, Varig 254.

(narrator): Thankfully,
his strategy works.

- Varig 254, Belém Tower.
Go ahead.

- Belém, we're on approach,
but we aren't seeing the VOR.
Is the beacon down?

- Negative, 254.
Looks like it's on your end.

- Understood.

(narrator): The crew
will have to approach Belém

without the help
of the VOR signal.

The captain checks his system
and calculates
when they'll arrive.

- Belém, we're 25 minutes out.

Request descent
for final approach.

- Roger, Varig 254.

Cleared to flight level 2-0-0.

(narrator): As the plane drops
below the clouds,

the captain looks
for the lights of Belém.

- Where are the lights?

Where's the airport?

(narrator):
But there's only darkness.

- No visible lights, Captain.

(narrator): In Belém,
the controller is concerned.

Flight 254 should have landed
by now.

But he doesn't have a radar,
so he has no way
of tracking the plane.

- We need to land soon,
or else we're gonna run
out of fuel!

- I think we're close.

(narrator): The captain searches
for a local radio signal,

hoping it will guide them
towards the city.

- Now we can follow the signal
towards Belém.

- Turning right, heading 1-6-5.

(narrator):
After 2.5 hours in flight,

the captain is confident
he's now on course.

- There we go.

We're over the Amazon now.

(narrator): Belém is near
the mouth of the Amazon.

Following the river
should lead the pilots
to the city.

But seconds later...
(alarm sounding)

- We've got a fuel warning!

(narrator): ...Flight 254
is running out of fuel.

The pilots suddenly realize
they can't make it to Belém.

- Flaps to 2. We need to do
a controlled descent.

(narrator): They'll have to make
a forced landing
in the dense Amazon rainforest.

- We just lost an engine!

- Hang on.
(alarm sounding)
I'm going to put her down.

- There goes the other one!

(narrator):
The inevitable impact
is just seconds away.

(automation): Terrain. Pull up.
- Just... need... to...

bring us down!

Nice... and... slow!

(alarm sounding)
(automation): Pull up.

(narrator):
Of the 54 passengers and crew,
six die on impact.

Many are badly hurt,
including First Officer Zille.

(baby crying)

The captain tends to the wounded
while they wait to be rescued.

- Ah!
(clattering)
(man): Help.

(narrator): But no one
in the outside world knows
where the plane has gone down.

(narrator):
Investigators conduct
an aerial search around Belém

for Varig Flight 254.

But there's no sign
of the missing aircraft.

(interpreter for Machado):
You get anxious to find
the plane quickly,

because people have
a better chance of survival
during the first 48 hours.

After that, survivors
are more likely to die.

(narrator): After two nights
in the jungle,

a small group sets off
to find help.

Hours later,
they stumble on a farmhouse.

- They found survivors!

(interpreter):
It's sort of a relief to realize
the scenario is not as tragic,

and there's an urgent desire
to get to the location
and start to work.

- Where did you say they are?

(narrator): The crash site
is nowhere near Belém.

- It came down right... here.

(narrator): The wreckage
of Flight 254 is lying
in the Amazon jungle,

nearly 700 miles away.

- How on earth did they get
way over there?

No wonder we couldn't spot
the beacon.

It's nowhere near
the destination.

(narrator): Within hours,

Brazilian military reach
the remote crash site
of Varig 254.

They find 43 survivors.

Five people have died
waiting for rescue,
and another dies soon after.

Shortly after
the rescue efforts,
there's a major breakthrough:

the discovery of the plane's
two flight recorders.

Investigators hope
they will reveal why Flight 254
was so badly off course.

(interpreter):
We were relying on the two
flight-data recorders.

Both pilots were alive,
so we thought we were certain
to come to a conclusion.

(narrator):
But when investigators review
the flight data,

it paints a confusing picture.

Instead of flying north
to Belém,

the plane took off west
and flew in the wrong direction
the entire flight.

(interpreter):
This became a central focus
of the investigation,

to know why the aircraft
was so far off course.

(narrator): Investigators wonder
if the crew were given
the wrong navigation details.

Thankfully, Flight 254's
flight plan from the airline

is among the documents
recovered from the cockpit.

- Oh, thanks. Let's see
what this will tell us.

I think I know
what they did wrong.

(Fox): Their computer
flight-plan system
has four digits.

This is very, very unusual,
as they almost always, uh,
have only three.

The number 0270...

was intended to mean...

27.0 degrees.

(interpreter):
When we noticed that,

it gave us the idea
that instead of entering 027,

which was the heading to Belém,
he had entered 270.

- The captain read it
as 270 degrees,

or due west,
so instead of flying
northeast...

- They went west instead,

going 270.

He entered the wrong heading.

(narrator):
Flying for more than three hours
in the wrong direction...

...investigators suspect
the aircraft ran out of fuel,

forcing the crew to make
a crash landing in the Amazon.

To confirm their suspicions,

they call in Captain Garcez
to tell his side of the story.

- I'll try to help you.

(narrator):
Under intense questioning,

he admits he misread
the flight plan,

causing the aircraft to fly
hundreds of miles off course.

- Look,
it was an honest mistake.

(narrator): Company records show
the airline began printing
their flight plans in a new way

while the captain
was on vacation.

- It's easy to see
how you'd get confused.

(interpreter):
From that moment on,

the cause or the basic framework
of the accident was determined.

(narrator):
But the first officer
was also required

to enter the heading
from the flight plan.

Why didn't he catch
the captain's mistake?

Aviation Psychologist
Kathy Mosier provides insight.

- The co-pilot,
probably after many experiences
with captains

who had always done it right
and never had to double-check,

just entered
what the captain had put in,

and assumed
that it was the right thing.
So in this case,

your safeguard is gone,
because the co-pilot
is not crosschecking.

- The original...

navigation mistake, um,
was that of the captain.

What is disheartening here
is that both pilots
went along with it.

(narrator): Flight 254 was
flying in the wrong direction
from the moment it took off.

Instead of asking for help,

the captain tried
to get back on course
using a local radio signal.

He thought he found a station
in Belém,

but instead picked up a signal
in the opposite direction,

taking them further away
from their destination.

(interpreter):
His pride prevented him
from saying to his colleague:

"Help me. I'm in trouble."
That would've been
a better approach.

(narrator):
While scanning their radar,

the crew thought they spotted
the Amazon River,

which would take them
back to Belém.

But the river they saw
was the Xingu,

more than 600 miles
southwest of Belém.

- How could they be so confused
for so long?

- I think we're close.

(narrator):
Investigators conclude the crew
was in the grip

of what's known
as confirmation bias...

...the tendency to favour
information that confirms
something we already believe.

- When I saw the river,
I was sure.

I was sure we were close
to Belém.

- It just goes to show you
anybody can...

fall into decision traps,

and even experts
have to always be on guard.

(narrator): The accident report
faults both pilots
for the actions

that caused the plane
with 54 people on board

to run out of fuel
and crash in the jungle.

After the crash of Varig 254,

the airline changes
their flight plans,

so the decimal place
is clearly marked.

They also improve
pilot training.

Brazil's national radar system
is modernized and expanded
to cover the entire country,

making it less likely
that a plane would go missing.

- Fuel management in flight
is the responsibility

of the pilots in the cockpit.

But you can have
those same human errors
on the ground.

The big common thread
between these three accidents

is the human factor.

It is the responsibility
to have not only a knowledge
of what you're doing,

but a fundamental understanding
so that you can execute
properly.

Subtitling: difuze