Investigation Summary
The flight was the first leg of a 15-day package holiday to the Costa Brava. At 22:04, the crew reported to Perpignan air traffic control that visibility was good and they were beginning their descent. However, shortly after this routine communication, the aircraft struck the 9,000-foot Mount Canigó to the southwest of the airport. The French Ministry of Transport's investigation focused on why an experienced crew would fly into a well-known mountain in good visibility. Forensic evidence eventually pointed to carbon monoxide poisoning. A leak in the aircraft's combustion heater allowed toxic fumes to enter the cockpit, causing the crew to suffer from cognitive impairment. This impairment resulted in a series of navigational errors and the failure to use radio directional finding equipment to verify their position relative to the high terrain.
Final Conclusions
The primary cause was the incapacitation of the flight crew due to carbon monoxide poisoning, which originated from a faulty cabin combustion heater. This led to a total failure to follow the prescribed VDF (Very High Frequency Direction Finding) approach procedure and a failure to maintain a safe altitude. The language barrier between the British crew and French ATC was a secondary contributing factor that prevented the controller from effectively identifying and correcting the crew's erroneous position reports.
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Crew Experience
Captain
Age 40. Held a valid commercial pilot's license.
First Officer
Age 33. Held a valid commercial pilot's license.
Systems & Failure Modes
Cabin Heater
A combustion-style heater that developed a fault, allowing carbon monoxide to leak into the cockpit and cabin air supply.
Radio Directional Finding (RDF)
Navigation equipment that was available but not utilized by the crew to determine their exact position during the approach.
Interesting Facts
- 01The accident remains the deadliest aviation disaster involving the Douglas DC-4 airframe.
- 02The aircraft was originally built as a C-54A Skymaster for the US Army Air Forces in 1942.
- 03The flight was a non-scheduled charter carrying 83 passengers on a package holiday organized by Lyons Tours.
- 04Investigators noted that language barriers between the crew and ATC may have aggravated the situation.
- 05The crash occurred during a 'disaster weekend' for British aviation, occurring less than 24 hours before the British Midland Argonaut crash at Stockport.
Safety Actions & Advisories
Special Review of UK Operators
Following the Perpignan and Stockport disasters, the UK Board of Trade initiated a special review of the safety performance and standards of all United Kingdom registered aircraft operators.