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Final investigation report released into Germanwings flight 4U9525 pilot suicide accident
13 March 2016
Germanwings crash-site (BEA)

Germanwings crash-site (BEA)

The French BEA published the final report of their investigation into the pilot suicide/intentional accident of a Germanwings Airbus A320 that crashed near Prads-Haute-Bléone, France, killing all 150 on board.

Germanwings flight 9525 departed Barcelona, Spain at 10:00 hours local time (09:00 UTC) on a regular passenger service to Düsseldorf, Germany. The flight reached its cruising altitude of FL380 at 10:27 hours. Three minutes later the captain left the cockpit. Soon thereafter the copilot changed the altitude on the Flight Control Unit (FCU) from 38,000 ft to 100 ft. The aircraft entered a descent during which the copilot made several adjustments to the selected descent speed. He did not respond to calls from air traffic control, nor did he react to the captain who requested him to open the cockpit door. At the final part of the descent it was attempted to break down the enforced cockpit door, but these attempts failed. At 10:41 the aircraft impacted mountainous terrain.

The investigation revealed a.o. that a doctor had advised the copilot to seek treatment at a psychiatric hospital, two weeks before crash. The copilot suffered from a mental disorder with psychotic symptoms. He was worried about impaired vision, which could end his carreer as airline pilot. Specialists found nothing wrong with his eyes and it was determined he suffered from psychosomatic disorder. He was also prescribed medicines like Mirtazapine.

Causes:
The collision with the ground was due to the deliberate and planned action of the co-pilot who decided to commit suicide while alone in the cockpit. The process for medical certification of pilots, in particular self-reporting in case of decrease in medical fitness between two periodic medical evaluations, did not succeed in preventing the co-pilot, who was experiencing mental disorder with psychotic symptoms, from exercising the privilege of his licence.
The following factors may have contributed to the failure of this principle:
– the co-pilot’s probable fear of losing his ability to fly as a professional pilot if he had reported his decrease in medical fitness to an AME;
– the potential financial consequences generated by the lack of specific insurance covering the risks of loss of income in case of unfitness to fly;
– the lack of clear guidelines in German regulations on when a threat to public safety outweighs the requirements of medical confidentiality.

Security requirements led to cockpit doors designed to resist forcible intrusion by unauthorized persons. This made it impossible to enter the flight compartment before the aircraft impacted the terrain in the French Alps.

Recommendations:

  • EASA require that when a class 1 medical certificate is issued to an applicant with a history of psychological/psychiatric trouble of any sort, conditions for the follow-up of his/her fitness to fly be defined. This may include restrictions on the duration of the certificate or other operational limitations and the need for a specific psychiatric evaluation for subsequent revalidations or renewals.
  • EASA include in the European Plan for Aviation Safety an action for the EU Member States to perform a routine analysis of in-flight incapacitation, with particular reference but not limited to psychological or psychiatric issues, to help with continuous re-evaluation of the medical assessment criteria, to improve the expression of risk of in-flight incapacitation in numerical terms and to encourage data collection to validate the effectiveness of these criteria.
  • EASA, in coordination with the Network of Analysts, perform routine analysis of in-flight incapacitation, with particular reference but not limited to psychological or psychiatric issues, to help with continuous re-evaluation of the medical assessment criteria, to improve the expression of risk of in-flight incapacitation in numerical terms and to encourage data collection to validate the effectiveness of these criteria.
  • EASA ensure that European operators include in their Management Systems measures to mitigate socio-economic risks related to a loss of licence by one of their pilots for medical reasons.
  • IATA encourage its Member Airlines to implement measures to mitigate the socio-economic risks related to pilots’ loss of licence for medical reasons.
  • EASA define the modalities under which EU regulations would allow pilots to be declared fit to fly while taking anti-depressant medication under medical supervision.
  • The World Health Organization develop guidelines for its Member States in order to help them define clear rules to require health care providers to inform the appropriate authorities when a specific patient’s health is very likely to impact public safety, including when the patient refuses to consent, without legal risk to the health care provider, while still protecting patients’ private data from unnecessary disclosure.
  • The European Commission in coordination with EU Member States define clear rules to require health care providers to inform the appropriate authorities when a specific patient’s health is very likely to impact public safety, including when the patient refuses to consent, without legal risk to the health care provider, while still protecting patients’ private data from unnecessary disclosure. These rules should take into account the specificities of pilots, for whom the risk of losing their medical certificate, being not only a financial matter but also a matter related to their passion for flying, may deter them from seeking appropriate health care.
  • Without waiting for action at EU level, the BMVI and the Bundesärztekammer (BÄK) edit guidelines for all German health care providers to:
    – remind them of the possibility of breaching medical confidentiality and reporting to the LBA or another appropriate authority if the health of a commercial pilot presents a potential public safety risk.
    – define what can be considered as “imminent danger” and “threat to public safety” when dealing with pilots’ health issues
    – limit the legal consequence for health care providers breaching medical confidentiality in good faith to lessen or prevent a threat to public safety
  • EASA ensure that European operators promote the implementation of peer support groups to provide a process for pilots, their families and peers to report and discuss personal and mental health issues, with the assurance that information will be kept in-confidence in a just-culture work environment, and that pilots will be supported as well as guided with the aim of providing them with help, ensuring flight safety and allowing them to return to flying duties, where applicable.

More information:

BEA Final Report (PDF)