Investigation Summary
The flight was the final leg of a long-haul service from Moscow with stops in Frankfurt and Lisbon. After a crew change in Lisbon, the aircraft proceeded toward Havana. During the descent, the crew encountered localized fog and reported seeing false altitude readings. Investigation later determined that the crew had not updated their barometric altimeters to the local airfield pressure (QFE). While the actual atmospheric pressure at the time was 758 mmHg, the crew failed to set the required QFE, with some reports indicating they were operating with a setting of 752 mmHg, causing the instruments to indicate the aircraft was higher than its actual altitude. Additionally, the crew performed a turn onto the final approach heading only 9 kilometers from the threshold, significantly closer than the standard 14 to 15 kilometers prescribed by procedure. Despite the lack of visual contact with the runway due to fog, the crew continued descending below the decision height of 150 meters. Some reports, including contemporary news accounts, suggested the aircraft was attempting an emergency landing due to an engine fire, though official findings focused on CFIT and altimeter errors.
Final Conclusions
The investigation concluded the primary cause was a blatant violation of approach procedures, specifically the crew's attempt to conduct a visual approach in weather conditions below minimums. Contributing factors included the failure to set the barometric altimeters to QFE, incorrect use of the radio altimeter, and navigational errors that led to a premature descent into obstacles.
Photographic Evidence (1)
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Systems & Failure Modes
Barometric Altimeter
The crew failed to set the correct local pressure (QFE), leading to an altitude display error.
Radio Altimeter
The investigation cited incorrect use of the radio altimeter during the final approach phase.
Interesting Facts
- 01The aircraft was only two years old at the time of the accident.
- 02The actual atmospheric pressure (QFE) at the time was 758 mmHg, but the crew failed to update their altimeters correctly.
- 03The crash occurred in a dense fog bank with vertical visibility of only 40 meters.
- 04The aircraft struck the ground 121 meters to the right of the extended runway centerline.
- 05Among the fatalities was José Carlos Schwarz, a prominent poet and musician from Guinea-Bissau.
Safety Actions & Advisories
Approach Discipline
The investigation emphasized the necessity of adhering to established approach distances and decision heights, especially in marginal weather.
Known Controversies & Unanswered Questions
Engine Fire vs. CFIT
Reference ↗While the official investigation focused on altimeter errors and a premature descent (CFIT), some sources and contemporary news reports (cited by Wikipedia and Flight International) claimed the aircraft was attempting an emergency landing due to an engine fire.
Ground Fatality and Occupant Count
Reference ↗There are conflicting reports regarding the total death toll. While official records state 67 fatalities among 69 occupants, some sources suggest a 70th person (a driver on the ground) was killed, or that the total number of occupants was 70.