Investigation Summary
The collision occurred at approximately 11:49 EST. The Cubana DC-4, named 'Estrella de Cuba', was cruising south at 4,000 feet as cleared by Air Traffic Control. Simultaneously, the Navy SNB-1 was performing a training mission that involved flying inbound on the east leg of the Key West Radio Range. Although the Navy flight was practicing 'blind' instrument flying, safety protocols required one pilot to maintain visual observation at all times. Investigation revealed that neither crew took evasive action, suggesting they were unaware of the other's presence until the moment of impact. The DC-4's left wing was sheared off opposite the outer engine, leading to the aircraft assuming a nose-down attitude before crashing into the ocean near the 'Little White House' presidential retreat.
Final Conclusions
The Civil Aeronautics Board (CAB) determined the probable cause was the failure of both flight crews to maintain sufficient vigilance to see and avoid other traffic while operating under Visual Flight Rules. Despite the Navy aircraft being on a training mission and the airliner being on a cleared airway, the clear weather conditions placed the primary responsibility for separation on the pilots' visual lookout.
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Cubana de Aviación CU493 — Douglas DC-4 · CU-T188
United States Navy Navy 39939 — Beechcraft SNB-1 Kansan · 39939
Crew Experience
Captain
Javier Z. Bazan
First Officer
Jesus F. Pacheco
Systems & Failure Modes
Visual Flight Rules (VFR)
The regulatory framework requiring pilots to maintain their own separation from other aircraft by visual observation.
Key West Radio Range
The navigational aid the Navy aircraft was using to fly a specific heading (250 degrees) during its training mission.
Interesting Facts
- 01The collision occurred in clear and calm weather conditions with excellent visibility.
- 02The DC-4 crashed into the ocean approximately 1.7 miles southeast of the collision point.
- 03The Navy Beechcraft disintegrated immediately upon impact and fell two miles west of the transport's wreckage.
- 04The DC-4 was carrying 34 passengers and 5 crew members; the Navy aircraft carried 4 crew members.
- 05Witnesses reported the DC-4's left wing was sheared off during the collision.
Safety Actions & Advisories
ATC Procedure Review
The CAB Chairman recommended that the Civil Aeronautics Administration review Air Traffic Control procedures and operational practices in the Key West area to prevent future conflicts between civilian and military traffic.