Investigation Summary
The flight was scheduled from Quito to Havana with an intermediate stop in Guayaquil. During the initial engine start at the gate, a pneumatic valve blocked, preventing the number one engine from starting. After a 38 minute delay, the issue was rectified; some later accounts suggested the valve was struck with a hammer to release it, though this remains an unconfirmed rumor. The crew started two engines using ground power and taxied toward the runway, starting the third engine while in motion to save time. The crew made two initial attempts to depart that resulted in rejected takeoffs for reasons that remain unclear, though survivors suspected engine issues. During the taxi and subsequent third takeoff roll on Runway 35, the crew failed to complete the final items of the taxi checklist, which included activating the hydraulic valves for the control surfaces. As the aircraft reached rotation speed (Vr), the pilot pulled back on the yoke, but the elevators did not respond because the hydraulic system was not pressurized to the control surfaces. The crew waited approximately 10 seconds after the failed rotation attempt before deciding to abort the takeoff. With only 800 meters of runway remaining, the aircraft could not stop, overshooting the perimeter fence and plowing into buildings and a soccer field where children were playing.
Final Conclusions
The investigation concluded that the primary cause was pilot error due to the omission of the taxi checklist. The crew's preoccupation with the mechanical delays and the unconventional engine start procedure led to a breakdown in standard operating procedures. Specifically, the failure to select the switches for the hydraulic valves of the control system meant the aircraft was physically incapable of lifting off. The high altitude of Quito (2,850 meters) and the airport's proximity to densely populated residential areas significantly exacerbated the fatality count, leading to 10 deaths on the ground.
Photographic Evidence (1)
Video Analysis
How This Plane Couldn't Take-off (Cubana Flight 389) - DISASTER BREAKDOWN — An analysis of the 1998 Cubana Flight 389 accident in Quito, exploring how a simple checklist omission led to a fatal runway excursion.
If playback is blocked, the owner has disabled embedding — use the link above.
Airframe & Maintenance
Systems & Failure Modes
Hydraulic Control Valves
Switches that must be manually selected to allow hydraulic pressure to reach the elevator, aileron, and rudder actuators.
Pneumatic Start Valve
A valve that failed initially, causing a delay and contributing to the crew's rushed state and checklist omission.
Interesting Facts
- 01The aircraft was a Tupolev Tu-154M manufactured in 1985 with 9,256 total airframe hours.
- 02Ten people on the ground were killed, including five children playing in the soccer field.
- 03The crash site was located approximately 180 meters north of the runway threshold.
- 04The flight was carrying 14 crew members, all of whom perished in the accident.
- 05Survivors escaped through a hole in the fuselage as several cabin doors failed to open after impact.
Safety Actions & Advisories
Runway Safety Area Construction
Source ↗In 1999, the DGAC commenced construction of a runway safety area at the end of the runway. The project involved erecting a 280-meter long and 92-meter wide berm-like platform to provide excursion space. This included building a tunnel for Tufino Avenue to allow traffic to pass under the new safety structure.
New Airport Development
Source ↗Following the accident, President Jamil Mahuad promised to build a new airport away from the densely populated urban center. Although delayed by economic crisis, construction of the new Mariscal Sucre International Airport began in 2006 and it opened in 2013, 18 kilometers east of the city.