What happened
On February 26, 2000, a Robin DR400-120, registration F-GOVO, departed from Chaumont-Sémoutiers for a local flight. During the flight, the pilot became lost and eventually landed at Saint-Florentin, approximately 50 NM away, after navigating by following a river. After refueling, the pilot departed Saint-Florentin at approximately 16:00 UTC.
As night fell, the pilot was unable to determine his position or remaining fuel. At 18:40, an instructor at Lunéville heard a distress call on the 123.5 MHz frequency and assisted the pilot in contacting air traffic control. While controllers attempted to guide the aircraft to Metz-Nancy-Lorraine, the pilot struggled with radio frequency adjustments and navigation. At 18:52, the aircraft struck a wooded hilltop at an altitude of approximately 1,300 feet. The impact resulted in one fatality and the total destruction of the aircraft.
The investigation
The investigation examined the wreckage, the aircraft's engine, and the pilot's recent flight history. Investigators found that the engine was producing power at the moment of impact and the aircraft was in a cruise configuration at a speed of 110 kt. The altimeter was set to a pressure corresponding to the Chaumont-Sémoutiers airfield.
Analysis of the pilot's records revealed that he had not performed a navigation flight since May 1998 and had very limited recent flight experience. Furthermore, while the pilot's medical certificate was current, investigators discovered that the pilot was undergoing a medical treatment that was not disclosed to his aviation medical examiner. Post-mortem analysis also noted an abnormally high level of carbon monoxide, though investigators determined this level was likely not representative of the pilot's state prior to the crash.
Findings
- The pilot's inability to maintain navigation skills led to him becoming lost and unable to maintain a safe altitude.
- The pilot's lack of recent navigation training meant he could not effectively use available tools, such as the GPS (which was found turned off) or the VOR.
- Increasing workload during communications with air traffic control contributed to a degradation in altitude maintenance.
- The pilot's medical condition and undisclosed medication may have impaired his judgment and ability to manage the emergency.
- Night operations and the loss of visual ground references made it impossible for the pilot to maintain terrain clearance.