1998-07-30: Beechcraft 1900D (F-GSJM) — Proteus Airlines — Quiberon, France

14 fatalitiesQuiberon, FranceFlight

A mid-air collision between a Beech 1900D and a Cessna 177 Cardinal resulted in the deaths of all 15 people on board near the Bay of Quiberon.

What happened

During a flight originating from Lyon-Satolas Airport, the crew of a Beech 190able 1900D requested permission from air traffic control to deviate from their IFR flight plan. The intent was to perform a visual circuit over the Bay of Quiberon to allow passengers to view the vessel 'Norway' (formerly France). While operating under VFR at an altitude of 2,000 feet in favorable weather conditions, the Beech 1900D collided with a Cessna 177 Cardinal, registration F-GAJE, which was operated by the Aéro Club de Vannes.

The impact caused both aircraft to enter an uncontrolled descent. The wreckage fell into the Bay of Quiberon, approximately 10 km from Quiberon and roughly 1,500 meters from the target ship. The accident resulted in 15 fatalities, including all 14 occupants of the Beech 1900D and the pilot of the Cessna 177.

Findings

Investigations concluded that the collision occurred because neither crew successfully detected the other aircraft while operating in uncontrolled Class G airspace, where pilots are responsible for their own separation via the "See and Avoid" principle. The decision to alter the flight trajectory into an improvised pattern created an unusual situation for a commercial transport aircraft.

Several contributing factors were identified:

  • The two aircraft were communicating on different frequencies, leaving both crews unaware of each other's presence.
  • The crew of the Beech 1900D was distracted by the observation of the ship 'Norway'.
  • Cockpit ergonomics and internal organization within the Beech 1900D hindered effective external monitoring during turns.
  • Blind spots on the Cessna 177 likely obscured the larger aircraft from the pilot's view.
  • Solar positioning may have impaired the visibility of the pilot in the Cessna.
  • The transponder on F-GAJE was inactive, preventing air traffic controllers in Lorient from identifying the aircraft on radar and providing necessary traffic alerts.

Probable cause

The collision was caused by a failure to visually detect the other aircraft in uncontrolled airspace, exacerbated by a decision to fly an improvised trajectory for sightseeing.