Taken in isolation, this accident is simply the case of a crew missetting their altimeters, confusing inches with millibars. But there is much more to it than that.
This was another incident in a series of 13, 11 of which pointed to a problem with the Crew Resource Management culture at Pan American World Airways at the time. They were able to reverse this culture and became one of the safest airlines in the world.
There isn't much available about this crash other than the basic facts. (If you have access to more, please hit the "contact" button and let me know.) It does beg the question: how can the world's premier international airline (at the time) have pilots who would have made such a basic mistake. I think it was a part of the airline's culture: their pilots were not subject to a lot of oversight. To learn more about this culture, see: Crew Resource Management. There are lessons that still apply today.
Everything here is from the references shown below, with a few comments in an alternate color.
The existing thoughts on this accident point to QFE versus QNH as well as confusing millibars (or Hecto Pascals) with inches. The aircraft "descended below decision height" on a visual approach. I'm not sure how they came up with a 360 foot difference. We clearly don't have all the facts here.
There is a lot of missing information, but given what is said about this accident:
What little exists "out there" points to the crew setting the wrong value in their altimeters and ending up flying below a safe approach altitude.
I don't have any primary source material on this crash. Can you help? Please hit the "contact" button and let me know.
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