Original subtitles

[downbeat music]

We just lost 1 and 2.

NARRATOR: All four engines shut down on a jet headed

straight for a US suburb.

[suspenseful music]

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.

[suspenseful music]

NARRATOR: In Japan, a plane catches fire

with all 165 passengers and crew still onboard.

The only time you have too much fuel

onboard the aircraft is when you're on fire.

We just lost an engine!

Hang on.

[suspenseful music]

NARRATOR: And the crew of a 737 is forced to make a crash

landing in the Amazon Jungle.

Something is very, very, very wrong here.

[suspenseful music]

NARRATOR: Three mysterious accidents send investigators

hunting for clues.

[suspenseful music]

Is it possible these tragedies all share the same cause?

WOMAN (VOICEOVER): Ladies and gentlemen,

we are starting our approach.

MAN (VOICEOVER): We lost both engines.

WOMAN (VOICEOVER): --emergency liftoff.

MAN (VOICEOVER): Mayday, mayday.

WOMAN (VOICEOVER): Brace for impact!

[shattering]

MAN (VOICEOVER): I think I lost one.

MAN (VOICEOVER): Investigation starting--

MAN (VOICEOVER): He's gonna crash!

[air whooshing]

[downbeat music]

[air whooshing]

NARRATOR: United Airlines Flight 173

is 22 miles away from Portland International Airport.

[downbeat music]

The 189 passengers onboard 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.

[mid-tempo music]

First Officer Rod Bibby has more than 5,000 hours

flying experience.

[mid-tempo music]

Flight engineer Forrest Mendenhall

is the third crew member.

OK.

NARRATOR: He's tasked with monitoring the DC-8's engines.

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

[mid-tempo music]

United 173 heavy.

OK, rollout heading 010 to runway 28 left.

NARRATOR: Air traffic controller Ed Kingrey

clears Flight 173 to land.

[air whooshing]

[suspenseful music]

Suddenly, an alarm sounds in the cockpit.

[beeping]

We're losing an engine.

[rapid beeping]

[suspenseful music]

It's flamed out.

You're going to lose number 3 in a minute, too.

[engines whirring]

NARRATOR: Two of the plane's four engines

have just shut down.

You've got to keep them running, Frosty.

Yes sir.

NARRATOR: The engineer struggles to keep

the last two engines running.

[suspenseful music]

How far do you show us in 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.

[suspenseful music]

We just lost 1 and 2.

[beeping]

[suspenseful music]

NARRATOR: Flight 173 has now lost all four engines.

[suspenseful music]

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

Captain McBroom makes a horrifying calculation.

I can't make it.

I can't make anything.

OK, declare mayday.

Portland tower, United 173.

Heavy mayday.

The engines are flaming out.

[mid-tempo music]

NARRATOR: McBroom needs to find a safe place

to put the aircraft down and try to save

the lives of all onboard.

[mid-tempo music]

ED KINGREY (VOICEOVER): I could see

him coming in from the south, his navigational lights

flashing.

You could tell he was quite low.

[rumbling]

[whimpers]

[suspenseful music]

[crashing]

I saw the bright flash out there and--

and knew he had gone down.

[suspenseful music]

NARRATOR: The DC-8 has crash-landed in a wooded suburb

in Portland, Oregon.

[downbeat music]

[dog barking]

Eight passengers and two members of the crew are dead.

[dog barking]

[downbeat music]

Incredibly, 179 people survive.

[downbeat music]

REPORTER (VOICEOVER): A United Airlines plane

crashed 5 miles southeast of Portland Airport

in a residential area.

Two homes were hit.

One disintegrated.

[downbeat music]

NARRATOR: Next morning, investigators

from the National Transportation Safety Board are on the scene.

One of the team members is human factor specialist Alan Diehl.

[downbeat music]

[camera clicking]

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

I realized this could have been one of the worst

accidents in history.

[downbeat music]

NARRATOR: Investigators hope survivors

can provide some insight into what brought this jet down.

When did you first notice something out of the ordinary

Um--

NARRATOR: They learned from the passengers

that an hour before the crash, the captain

made an announcement.

[downbeat music]

CAPTIAN (ON INTERCOM): Ladies and gentlemen,

this is your captain speaking.

NARRATOR: The crew were having trouble with the landing gear.

CAPTIAN (ON INTERCOM): 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?

[suspenseful music]

[mid-tempo music]

NARRATOR: At the crash site, the plane's

flight recorders are recovered.

They're sent for analysis to the National

Transportation Safety Board headquarters in Washington.

[downbeat music]

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 them for an approach to runway 28.

I was about to hand them off to the tower controller.

Negative.

We'll stay with you.

We've got a gear problem.

We'll let you know.

ED KINGREY (VOICEOVER): He basically

said he'd stay with me.

That he was having some kind of 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.

[air whooshing]

NARRATOR: But Flight 173 circled Portland

for an unusually long time.

And 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--

them losing engines.

[suspenseful music]

There was no indication to me the gravity of the situation.

[suspenseful music]

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 going to be able to make it to the airport.

I was clearly very interested in, you know,

how a highly experienced captain could fly around

for over an hour inside of the airport, in good weather,

and not put this airplane on the ground safely.

[downbeat music]

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.

[downbeat music]

OK.

Let's go.

NARRATOR: If there was a malfunction,

he hopes the cockpit voice recorder picked

up the pilots discussing it.

CAPTIAN (ON RECORDING): Ladies and gentlemen,

this is your captain speaking.

NARRATOR: The recording begins 30 minutes before the crash,

as the pilots circle over Portland.

CAPTIAN (ON RECORDING): --correctly.

Because I've only got this thing to shine down there.

NARRATOR: They hear the flight engineer

leave the cockpit to troubleshoot

the landing gear problem.

[downbeat music]

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?

JOHN COX (VOICEOVER): 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?

Both appear to be down and locked.

[engines whirring]

NARRATOR: Despite his engineer's report,

Captain McBroom still sounds concerned.

[faint beeping]

There's one check we missed.

Checking the gear warning horn.

Uh-- 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.

[downbeat music]

Then investigators make a shocking discovery.

CAPTIAN (ON RECORDING): Losing an engine.

It's flamed out.

Why?

Fuel.

[sighs]

[suspenseful music]

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.

[suspenseful music]

You're going to lose number 3 in a minute, too.

NARRATOR: One by one, fuel starvation

shuts down all the engines, leaving

the DC-8 without any power.

[suspenseful music]

CAPTIAN (ON RECORDING): OK, declare mayday.

How could an experienced crew lose track

of how much fuel they had onboard,

and in fact, run out of fuel when they

were in view of the airport?

[downbeat music]

NARRATOR: Captain McBroom may be the only one

who can provide answers.

He's in the hospital recovering from injury,

but well enough to speak to investigators.

CAPTAIN MCBROOM: I recall seeing the number 1 and number

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.

[downbeat music]

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 they had.

We had 5,000 pounds.

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

and you can figure out how much fuel

they should have had remaining.

5,000.

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.

[beeping]

With mechanical failure ruled out,

the team now explores the human factors.

Specifically, Captain McBroom's behavior.

[mid-tempo music]

CAPTIAN (ON RECORDING): How much fuel do you got now?

CAPTIAN (ON RECORDING): 4,000. 4,000.

Any--

NARRATOR: Investigators played back the cockpit voice recorder

to study his performance.

[downbeat music]

CAPTIAN (ON RECORDING): How much fuel you got now?

NARRATOR: They hear something alarming in the conversation.

[faint beeping]

[downbeat music]

How much fuel we got now?

4,000.

4,000 in each.

Pounds.

[downbeat music]

[faint beeping]

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-- right.

CAPTAIN: 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 about something like fuel.

[suspenseful music]

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.

[downbeat music]

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.

[downbeat music]

NARRATOR: In a move that has a lasting impact on airline

safety, the Federal Aviation Administration

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 of the flight deck

to be respectfully assertive.

[downbeat music]

NARRATOR: If the crew of Flight 173 had received CRM training,

they might have insisted that Captain

McBroom land immediately.

Not enough.

15 minutes is really going to 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

have crashed in the interim.

[mid-tempo music]

[chatter]

NARRATOR: In 2007, a terrifying explosion reminds investigators

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

[suspenseful music]

[engines whirring]

[air whooshing]

China Airlines Flight 120 is on final approach

for landing in Okinawa, Japan.

[mid-tempo music]

[intercom dings]

CAPTIAN (ON INTERCOM): 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 a landing.

NARRATOR: The captain is 47-year-old You Chien-kou.

[downbeat music]

What's the weather for approach?

Cloud ceiling says 1,000 feet.

Wind's at 8 knots.

NARRATOR: The first officer is 26-year-old Tseng Ta-wei.

[downbeat music]

The pilots have more than 8,500 hours of flight

experience between them.

[engines whirring]

[downbeat music]

This morning, there are 157 passengers and 8 crew onboard.

Please put your tray up and fasten your seatbelt.

[engines whirring]

[mid-tempo music]

NARRATOR: The pilots reconfigure their plane as they slow down

and descend for landing.

[mid-tempo music]

Let's go to flaps 25.

Flaps 25.

NARRATOR: They deploy flaps from the wing's back edge,

along with slats from the front edge.

These devices keep the plane airborne at lower speeds.

[downbeat music]

[engines whirring]

MAN (ON RADIO): 30, 20, 10.

[engines whirring]

NARRATOR: It's a textbook landing.

[engines whirring]

Flaps up.

NARRATOR: All that's left for the China Airline

pilots is to park the plane.

[downbeat music]

Engine start levers

Engine start levers cut off.

Seatbelts.

Seatbelts off.

[intercom dings]

[downbeat music]

NARRATOR: Then one passenger notices

that something's not right.

[downbeat music]

[speaking japanese]

[suspenseful music]

[beeping]

Hey, what is this?

[beeping]

What's happening?

NARRATOR: Just when they thought they were safely parked--

MAN (ON RADIO): Cockpit, ground, number 2 engine fire.

NARRATOR: --a radio call alerts them

to a fire in the right engine.

MAN (ON RADIO): DYNASTY 120, we are calling a fire truck.

Remain.

Standby.

[suspenseful music]

[speaking japanese]!

Cabin crew, prepare for evacuation.

Prepare for evacuation.

[suspenseful music]

NARRATOR: Within minutes, the fire engulfs both wings.

[suspenseful music]

[grunts]

No pushing.

No pushing.

Please keep moving forward.

NARRATOR: Flight attendants work to evacuate the passengers

as quickly as possible.

The plane could explode at any moment.

[coughs]

Captain, all passengers are evacuated.

You're the last one.

[coughs]

[suspenseful music]

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.

Sir--

[chatter]

[screaming]

MAN: Oh.

Whoa!

[clamoring]

[downbeat music]

NARRATOR: Incredibly, both pilots evacuate just in time.

[sirens wailing]

[downbeat music]

All 165 people onboard escape unharmed.

[downbeat music]

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.

JF JOSEPH: It's highly unusual for an aircraft

to catch fire at that phase of the flight.

So that sparked a great deal of interest.

[radio chatter]

NARRATOR: A team of international air crash

investigators are immediately called in.

[radio chatter]

They need to find the cause before there's

another deadly explosion.

[radio chatter]

[mid-tempo music]

Across the globe, there are more than 5,000

Boeing 737's in service.

[downbeat music]

There's a 737 taking off and landing every 3

or 4 seconds in the world.

NARRATOR: Knowing countless passengers could be at-risk,

investigators raced to figure out

how an airliner that landed safely suddenly

burst into flames.

[mid-tempo music]

OK, let's get to work!

The challenge for investigators

is most of the evidence would 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.

So 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: The 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 the actual fuel leak had occurred,

it was a breakthrough.

A true breakthrough in the investigation.

[downbeat music]

We know the fuel was leaking.

But from where?

[drill whirring]

NARRATOR: Investigators examine what remains

of the 737's fuel tanks.

[downbeat music]

The tanks are made from aluminum alloy

and should never crack or leak.

[downbeat music]

They use a small camera called a borescope to see

inside the right fuel tank.

[downbeat music]

What it reveals changes the course

of the entire investigation.

[suspenseful music]

Whoa.

Would you look at that?

Airlines Flight 120, investigators find a bolt

lodged in the side of the tank.

All of a sudden, it clears a bell.

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

[downbeat music]

NARRATOR: The bolt has ruptured the tank right where the ground

worker spotted leaking fuel.

BOB BENZON: It's hard to describe

how significant this was I mean, this was

the core of the investigation.

[downbeat music]

[whirring]

[crackling]

NARRATOR: But where did the bolt come from?

OK.

Got it.

[downbeat music]

NARRATOR: Investigators compare the piece

to schematics of the 737 wing structure

to figure out exactly what it is.

[downbeat music]

They soon get their answer.

[downbeat music]

A downstop assembly.

NARRATOR: The downstop assembly is part of the slot 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.

[mid-tempo music]

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 punched through the tank.

Our next step was trying to figure out how this

could possibly have occurred.

[mid-tempo music]

NARRATOR: When comparing the downstop assembly from Flight

120 to Boeing's schematics--

[mid-tempo music]

--the team uncovers a vital clue.

BOB BENZON: 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.

MAN: Where is it?

[mid-tempo music]

NARRATOR: Could a single missing washer have

played a role in the accident?

[mid-tempo music]

MAN: All right.

Now let's test it without a washer.

[mid-tempo music]

NARRATOR: The team experiments with the suspicious bolt

from Flight 120 to see how it performs without the washer.

They make a stunning discovery.

[downbeat music]

The small washer is the only thing preventing the unit

from falling out of its mount.

Without the washer it fails.

[downbeat music]

NARRATOR: Investigators need to find out how the part

could have disappeared.

[downbeat music]

We went to China Airlines to ask them to demonstrate how

they do the maintenance work.

[mid-tempo music]

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

[mid-tempo music]

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.

[mid-tempo music]

NARRATOR: But reaching the downstop's location

proves challenging.

You can imagine that you are under the wing,

and you cannot see it.

[mid-tempo music]

[suspenseful music]

Sorry.

I just dropped it.

Don't worry.

It's-- it's easy to pick up again.

NARRATOR: It's an eye-opening demonstration.

[downbeat music]

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 have fallen off during the maintenance

procedure in Taiwan.

[suspenseful music]

The sequence of events that led to the devastating fuel fire

in Okinawa is finally clear.

[engines whirring]

Six weeks after the field 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.

[mid-tempo music]

[engines whirring]

Inside one of the track assemblies on the right wing,

the loosened bolt without a washer

is just barely holding on.

[engines whirring]

[tires screeching]

Touchdown is enough of a jolt to finally

knock it out of its track.

[mid-tempo music]

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 gallons of fuel to leak.

[mid-tempo music]

After-landing checklist.

NARRATOR: Once the pilots park and shut down the engines,

the leaking fuel starts dripping directly

onto the scorching-hot tailpipe, igniting on contact.

[suspenseful music]

In the wake of the China Airlines explosion,

aviation authorities around the world ordered the inspection

of entire fleets of 737's.

In the US 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.

[muffled speech]

NARRATOR: In Brazil, investigators

uncover another fatal problem when

a disastrous fuel failure brings down

a plane in the Amazon Jungle.

[crashing]

Brazil in the late 1980s is a country in transition.

Developing cities are scattered throughout the dense Amazon

Rainforest.

[mid-tempo music]

In Marabá, the crew of Varig Flight 254

is preparing for takeoff.

[mid-tempo music]

[speaking portuguese]

NARRATOR: There are 48 passengers onboard.

MAN (VOICEOVER): Pulling right now.

[engines whirring]

[downbeat music]

NARRATOR: Flight 254 is an hour-long flight

from the mining town of Marabá to Belém near the mouth

of the Amazon River.

[suspenseful music]

The crew dials in a compass heading to guide

them to their destination.

[engines whirring]

Here we go.

[suspenseful music]

NARRATOR: Captain Cézar Garcez is flying the airplane

tonight while first officer Nilson

Zille monitors the instruments.

B1.

Rotate.

[downbeat music]

NARRATOR: The Boeing 737 steadily

climbs to cruising altitude.

[downbeat music]

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.

[downbeat music]

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.

Hm.

That's funny.

What?

We're not picking up their 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.

[air whooshing]

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 to send for final approach.

Varig 254, clear to flight level 200.

[beeping]

[suspenseful music]

NARRATOR: As the plane drops below the clouds,

the captain looks for the lights of Belém.

Where are the lights?

[suspenseful music]

Where is the airport?

NARRATOR: But there's only darkness.

[suspenseful music]

No visible lights, Captain.

NARRATOR: In Belém, the controller's concerned.

Flight 254 should have landed by now.

But he doesn't have a radar, so he has

no way of tracking the plane.

[suspenseful music]

We need to land soon or else we're going to run out of fuel.

I think we're close.

NARRATOR: The captain searches for a local radio signal,

hoping it will guide them toward the city.

Now we can follow the signal towards Belém.

Turning right, heading 165.

[suspenseful music]

[engines whirring]

NARRATOR: After 2 and 1/2 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.

[suspenseful music]

But seconds later--

We've got a fuel warning!

NARRATOR: --Flight 254 is running out of fuel.

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

Flaps to 2.

We need to do a controlled descent.

[suspenseful music]

NARRATOR: They'll have to make a forced landing

in the dense Amazon Rainforest.

[suspenseful music]

We just lost an engine!

Hang on.

I'm going to put her down.

[suspenseful music]

But there goes the other one!

[suspenseful music]

NARRATOR: The inevitable impact is just seconds away.

Pull up.

Just need to bring us down nice and slow.

[suspenseful music]

[crashing]

[suspenseful music]

[crashing]

[suspenseful music]

NARRATOR: Of the 54 passengers and crew, six die on impact.

Many are badly hurt, including First Officer Zille.

[suspenseful music]

[baby crying]

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

[grunts] Hello?

NARRATOR: But no one in the outside world

knows where the plane has gone down.

[suspenseful music]

around Belém for Varig Flight 254,

but there's no sign of the missing aircraft.

[downbeat music]

INTERPRETER (VOICEOVER): 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.

[birds chirping]

[suspenseful music]

NARRATOR: After two nights in the jungle,

a small group sets off to find help.

[suspenseful music]

Hours later, they stumble on a farmhouse.

[suspenseful music]

They found survivors.

[muffled speech]

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.

[mid-tempo music]

Where did you say they are?

NARRATOR: The crash site is nowhere near Belém.

MAN: 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

reached the remote crash site of Varig 254.

They find 43 survivors.

Five people have died waiting for rescue,

and another dies soon after.

[downbeat music]

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.

DOUGLAS MACHADO: [speaking portuguese]

INTERPRETER (VOICEOVER): We were relying on the two flight data

recorders.

Both pilots were alive, so we thought we were certain to come

to a conclusion.

[speaking portuguese]

[mid-tempo music]

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.

[suspenseful music]

[speaking portuguese]

INTERPRETER (VOICEOVER): 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.

[downbeat music]

I think I know what they did wrong.

[downbeat music]

JOHN COX (VOICEOVER): Their computer flight

plan system has four digits.

This is very, very unusual, as they

almost always have only three.

The numbers "0270" was intended to mean 27.0 degrees.

[suspenseful music]

[speaking portuguese]

INTERPRETER (VOICEOVER): When we noticed that,

it gave us the idea that instead of entering "027,"

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

RONALDO JENKINS (VOICEOVER): [speaking portuguese]

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.

[downbeat music]

NARRATOR: Flying for more than 3 hours in the wrong direction--

[suspenseful music]

[whirring]

--investigators suspect the aircraft ran out

of fuel, forcing the crew to make

a crash-landing in the Amazon.

[suspenseful music]

[crashing]

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.

[downbeat music]

Look, [sighs] it was an honest mistake.

[downbeat music]

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.

[speaking portuguese]

INTERPRETER (VOICEOVER): 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 their flight plan.

[speaking portuguese]

NARRATOR: 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 cross-checking.

[downbeat music]

The original navigation mistake

was that of the captain.

What is disheartening here is that both pilots

went along with it.

[air whooshing]

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.

[suspenseful music]

[speaking portuguese]

INTERPRETER (VOICEOVER): His pride prevented him from saying

to his colleague, help me.

I'm in trouble.

That would have 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 can 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 favor information that confirms

something we already believe.

When I saw the river, I was sure.

I was sure we were close to Belém.

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 onboard 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.

[engines whirring]