Incident Overview

Date: Monday 10 April 1989
Aircraft Type: Fairchild FH-227B
Owner/operator: Europe Aero Service – EAS, lsf Uni-Air International
Registration Number: F-GGDM
Location: L‚oncel – ÿ France
Phase of Flight: Approach
Status: Destroyed, written off
Casualties: Fatalities: 22 / Occupants: 22
Component Affected: Aircraft Navigation System (VOR LSA), Air Data Display (VDO), Pilot’s Mental Representation, Airspace Organization, Task DefinitionAircraft Navigation System (VOR LSA), Air Data Display (VDO), Pilot’s Mental Representation, Airspace Organization, Task Definition
Investigating Agency: BEABEA
Category: Accident
EAS Flight 602 experienced a near-miss near a mountain intersection in Valence, France, resulting in a significant impact. The aircraft deviated from its planned route due to navigational errors, specifically utilizing a VOR LSA instead of the VNE, leading to a change in heading and subsequent collision with a mountain.EAS Flight 602 experienced a near-miss near a mountain intersection in Valence, France, resulting in a significant impact. The aircraft deviated from its planned route due to navigational errors, specifically utilizing a VOR LSA instead of the VNE, leading to a change in heading and subsequent collision with a mountain.

Description

EAS Flight 602 took off from Paris at 19:55 for a flight to Valance. The aircraft proceeded to Valence at FL130. At 20:43 the flight passed the Lespi intersection and continued on a 133deg heading to the VNE VOR. At 20:49 the aircraft was cleared to descend to FL70 and FL60 when approaching VNE VOR. At 20:56 the FH-227 passed the VNE VOR and was to head 178deg for Valence. The aircraft however continued on a 155deg heading. The heading was changed to 178deg at 21:04. At 21:07 the aircraft struck a mountain (Col de Tourniol) at 1260 m. PROBABLE CAUSE (translated from original French language report): “The accident is the direct result of a navigational error. This error had the direct causes: 1) the display and use the VOR LSA instead of VNE; 2) an insufficiency in the mental representation of the path of the aircraft despite other available information. Moreover, the lack of rigor in the division of work in their execution and in the mutual control are contributing factors. The Committee also noted that the following facts have facilitated the development of a critical situation: 1) documentation of the crew used for navigation and organization of the dashboard of the plane could be sources of error, 2) the organization of the airspace in the region of Valence did not allow optimal use of existing radar; 3) the tasks of the crew were not defined by the operator; 4) the co-pilot had a moderate but significant blood alcohol level.”

Primary Cause

Navigation error ? specifically, the use of a VOR LSA instead of the VNE, insufficient mental representation of the aircraft’s path, lack of rigorous division of work, inadequate airspace organization, and insufficient defined tasks.Navigation error ? specifically, the use of a VOR LSA instead of the VNE, insufficient mental representation of the aircraft’s path, lack of rigorous division of work, inadequate airspace organization, and insufficient defined tasks.

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