This article presents a case study of the accident with Varig flight RG-254 in September 1989. Using as starting point the official investigation data, publications, audiovisual material and interviews with those involved in the accident as well as flight safety specialists, the authors re-analyze the accident through a sociotechnical focus, which is based on the actor-network theory and concepts of "normal" accident. The text presents a new understanding of aviation accident investigation and it reviews the traditional terms of investigation based on a rigid division between "human", "technical" and "operational" factors. It also suggests the application of the multi-causality concept, which is not restricted to a mere list of "contributing factors", but which analyzes the relationships among the actor-networks involved in the aviation system where the accident occurred. The RG-254 accident is described as a symptom of the rupture of relationship among those acting in the system.
aviation accidents; actor-network theory; "normal" accidents
