Investigation Summary
The flight departed Paris-Orly at 19:55 for a non-scheduled charter service to Valence. During the descent, the crew was cleared to FL70 and subsequently FL60. The primary cause of the accident was the incorrect selection of the VOR frequency. Instead of tuning to the Valence VOR (VNE), the crew tuned to the Lyon Satolas VOR (LSA). This resulted in the aircraft following a 155-degree heading instead of the required 178-degree path after passing the VOR station. By the time the crew corrected their heading to 178 degrees at 21:04, they were significantly east of their intended track, positioned over the rugged terrain of the Vercors Massif. At 21:07, while flying at approximately 1,260 meters (4,134 feet), the aircraft struck the Col de Tourniol. The BEA investigation highlighted several contributing factors, including a lack of defined task sharing between the pilots, confusing cockpit documentation, and the presence of alcohol in the co-pilot's system, which likely impaired his monitoring capabilities.
Final Conclusions
The BEA concluded in report f-dm890410 that the accident was a direct result of a navigational error caused by the display and use of VOR LSA instead of VNE. Contributing factors included an insufficient mental representation of the flight path, lack of rigor in crew coordination, inadequate definition of crew tasks by the operator, and the co-pilot's moderate but significant blood alcohol level. The investigation also noted that regional airspace organization did not facilitate optimal radar use.
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Crew Experience
Captain
Co-Pilot
Post-mortem toxicology revealed a moderate but significant blood alcohol level.
Systems & Failure Modes
VOR Navigation
The crew incorrectly tuned the navigation radio to the LSA frequency, leading to a lateral deviation that placed the aircraft over mountains instead of the valley approach path.
Cockpit Documentation
The BEA noted that the navigation charts and dashboard organization used by the crew were potential sources of error.
Interesting Facts
- 01The aircraft was a Fairchild FH-227B built in 1966.
- 02All 22 occupants, including the crew and passengers, were killed in the impact.
- 03Post-mortem toxicology revealed the co-pilot had a moderate but significant blood alcohol level.
- 04The crew mistakenly used the Lyon Satolas (LSA) VOR frequency instead of the Valence (VNE) VOR.
- 05The aircraft was operated by Uni-Air International on behalf of Europe Aero Service (EAS).
Safety Actions & Advisories
Crew Task Definition
The investigation recommended that operators clearly define crew tasks and mutual control procedures to prevent single-point failures in navigation.
Location
ACCIDENT SITE · Coordinates taken from the entered by an editor.