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, a Beech 1900D (registration F-GSJM) operated by Proteus Airlines, was performing a scheduled passenger flight from Lyon Satolas to Lorient Lann-Bihoué. The flight crew, carrying 12 passengers, had requested a deviation from their original flight plan to observe the cruise ship *Norway* anchored in the bay.
After contacting Lorient approach, 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 Cessna 177 (registration F-GAJE) was conducting a local flight from Vannes, descending from 3,000 feet to 1,500 feet.
As the Beech 1900D was completing its turn and resuming its heading toward Lorient at approximately 2,000 feet, it collided with the Cessna 177. The collision resulted in 3 fatalities (two crew members from the Beech 1900D and the pilot of the Cessna 177) and the destruction of both aircraft.
The investigation
The BEA investigation examined the flight trajectories, radar data, and cockpit voice recordings from the Beech 1900D. Investigators analyzed the crew's decision-making process regarding the transition from IFR to VFR and their adherence to separation standards. The investigation also included a study by the Laboratory of Applied Anthropology to evaluate the psychophysiological and behavioral aspects of the crew's performance, specifically focusing on visual accommodation and divided attention during the maneuver.
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 engaged in multiple tasks, including navigating, communicating with air traffic control, and observing the cruise ship, which likely degraded their ability to monitor the surrounding airspace.
- The transition from IFR to VFR introduced increased complexity in maintaining situational awareness regarding other local VFR traffic.
- There were noted deficiencies in the pilot training regarding the physiological limitations of visual scanning and the management of divided attention in a cockpit environment.