What happened
On July 30, 1998, at 13:58 UTC, a mid-air collision occurred in Quiber andon Bay, France, involving two aircraft. The first aircraft, a Beech 1900D, registration F-GSJM, was operating a scheduled passenger flight (Proteus 706) from Lyon Satolas to Lorient Lann-Bihoué. The aircraft was carrying 14 people, including two infants.
During the descent, the crew of the Beech 1900D requested a deviation from their flight path to view the cruise ship *Norway*, which was anchored in the bay. After receiving clearance, the crew decided to cancel their IFR (Instrument Flight Rules) flight plan and transition to VFR (Visual Flight Rules) to perform a 360-degree turn around the vessel. Simultaneously, a private Cessna 177, registration F-GAJE, was conducting a local flight from Vannes, descending from 3,000 feet to 1,500 feet.
The collision occurred at approximately 2,000 feet altitude as the Beech 1900D was completing its turn and attempting to realign with its course toward Lorient. The impact resulted in 3 fatalities (two crew members and one pilot) and the destruction of both aircraft.
The investigation
The investigation examined the flight trajectories, air traffic control communications, and the crew's decision-making process. Investigators analyzed radar data and cockpit voice recordings from the Beech 1900D. The inquiry also included specialized studies on the psychophysiological and behavioral aspects of the crew, as well as simulations of TCAS (Traffic Alert and Collision Avoidance System) functionality to determine if such technology could have prevented the event.
Findings
- The primary cause of the accident was the failure to maintain the "see and avoid" principle during VFR operations.
- The crew of the Bee..'ch 1900D was distracted by the visual spectacle of the cruise ship, which compromised their situational awareness and monitoring of the surrounding airspace.
- The transition from IFR to VFR flight conditions introduced increased risks, as the crew was no longer under the direct separation services of air traffic control.
- There were identified deficiencies in the company's technical documentation provided to pilots regarding updated regulatory requirements.
- Physiological limitations, such as the latency in visual accommodation when switching focus between cockpit instruments and the external environment, contributed to the inability to detect the approaching Cessna 177.