By Nicholas Claich
Published on
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The accident claimed the lives of three people. On September 28, 2020, around 10:30 a.m., a small Cirrus SR-22 aircraft, which departed from the airport of Caen-Carpiquet (Calvados) two hours earlier, had crashed into a wood in the town of La Chevillotte, near Besancon (Doubs), its planned destination. Serge Lamy (73) and Jacques Gosselin (72), two friends from Caen, perished in the crash. They were accompanied by Noémie Samson, a young woman of 32, who had a business meeting in Besançon. She didn’t survive either.
Loss of control
On Friday March 11, 2022, the Bureau of Investigation and Analysis (BEA) for civil aviation safety issued its report, after a year and a half of investigation. According to the conclusions of the specialists, the pilot – Serge Lamy – would have “lost control of the plane”, when starting the final descent towards the aerodrome of Besançon – La Vèze.
The analysis of the parameters extracted from the radar data during the final approach shows deviations from the trajectory on either side of the nominal glide path, probably linked to significant input on the control column on the part of the pilot.
“Out of service” oxygen system
To explain this loss of control, while the pilot was described as “experienced” by members of the flying club The Wings of Calvados, of which he was a member, the investigators put forward several hypotheses. Due to the thick cloud layer prevailing that day, most of the flight took place above 3,000 meters, or even higher for an hour. Altitudes which require, according to the regulations, to have an oxygenation system in order to avoid situations of hypoxia, which can themselves cause “cognitive disorders”.
However, the on-board oxygen system was “out of service”, note the BEA investigators. “It is likely that the pilot used a pulse oximeter during the flight in order to assess his state of hypoxia, having used it in previous flights”, they observe. again.
In their report, they could not establish whether the autopilot was engaged or not, when approaching the final descent. On the other hand, they found that the safety parachute had been triggered “at an insufficient height”, which “did not allow its full deployment before the collision on the ground”.
However, the aeronautical specialists are not clear as to the reasons for this loss of control, the pilot having maintained “normal” communications with the control tower: “it was not possible to determine whether a post hypoxic may have contributed to the loss of control”. But they note “questionable management of subsistence oxygen and associated equipment, as well as gaps in the regulations and available documentation relating to the use of subsistence oxygen”.
Judicial investigation in progress
The court case is still ongoing. The Besançon prosecutor’s office had opened an investigation for “manslaughter”, as often in such cases. “We are awaiting this report,” indicate the services of the Doubian prosecutor.
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