Published on March 13th, 2016 | by Jim Lee0
French BEA publishes the Final Report into the fatal loss of Germanwings flight 4U9525
On 13th March 2016, the French BEA (Bureau d’Enquêtes et d’Analyses pour la sécurité de l’aviation civile), the French Civil Aviation Safety Investigation Authority, published the Final Report of the Safety Investigation into the fatal loss of Germanwings flight 4U9525, on 24th March 2015. The facts of the incident involving Germanwings Airbus A320-211, D-AIPX, operating flight 4U9525 between Barcelona (Spain) and Düsseldorf (Germany), with the callsign, GWI18G, which was carrying six crew and 144 passengers, are already well known, following the publication by the BEA of its preliminary report, on 6th May 2015 (see here). This report was prepared on the basis of the initial information gathered in the course of the investigation.
The investigation was helped by the early recovery of aircraft’s so called ‘black boxes’ from the crash site in the French Alps at Prads-Haute-Bléone (Alpes-de-Haute-Provence, France). The aircraft had crashed on the southern side of the Tête du Travers, a minor peak in the lower western slopes of the Tête de l’Estrop, three kilometres (2 miles) east of the settlement Le Vernet and beyond the road to the Col de Mariaud, in an area known as the Ravin du Rosé. The site is approximately 10 kilometres (6 miles) west of Mount Cimet, where an Air France Lockheed L-749 Constellation, F-BAZZ, operating a scheduled flight from Paris to Nice, as the Air France Flight 178, crashed on 1st September 1953.
The Cockpit Voice Recorder (CVR) was found on the afternoon of 24th March, with the Flight Data Recorder (FDR) later and this was sent to the BEA on 2nd April under judicial seal. From the read out of the data from the CVR, it appeared to the BEA that an act of “unlawful interference” was probably involved in the accident and the information was communicated immediately to the judicial authorities. In accordance with existing arrangements the BEA decided to continue the Safety Investigation. This Investigation was organised into three working groups, looking in detail at the aircraft, aeroplane systems and operations. The work performed by the working groups was included in the Draft Final Report, which was sent for consultation to the participants in the investigation, in December 2015. This was followed by a review and integration of the comments received and led to the drafting, then the publication of this Final Report, which can be found here .
Final Reports conclusions and a summary of the flight
The Final Report concluded that the collision with the ground was due to the deliberate and planned action of the co-pilot, Andreas Lubitz, who decided to commit suicide while alone in the cockpit. It also found that 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. In the previous 3 months he had flown 107 hours without incident and the same crew had made the outbound flight, taking off from Düsseldorf at 06:01 and landing in Barcelona at 07:57.
For the return flight, take-off from Barcelona took place at 09:00 from runway 07R (UTC) with the 27 year old German co-pilot as Pilot Flying (PF). He had commenced his basic training at the Lufthansa Flight Training (LFT) Pilot School in Bremen on 1st September 2008, but had suspended this training for medical reasons on 5th November of that year. He restarted his training on 26th August 2009 and in December 2013, he took and passed, his A320 type rating at Lufthansa in Munich having joined Germanwings. During the period 5th June 2011 to 31st December 2013, he was under contract as a flight attendant for Lufthansa while continuing his Air Transport pilot training. At the time of the crash he had amassed 919 flying hours with 540 flying hours on type.
Some 30 minutes after take-off, the Captain, 34-year-old Captain Patrick Sondenheimer, told the co-pilot that he was leaving the cockpit and asked him to take over radio communications, which he acknowledged. Less than a minute later, after crossing the French coast near Toulon, the aircraft left its assigned cruising altitude of 38,000 feet (12,000 m) and without approval began to descend rapidly. After a number of failed attempts by air traffic control to contact the aircraft, they declared the aircraft in distress due its unapproved descent and failure to respond.
Meanwhile, at 09:34:31, the CVR indicated that the buzzer to request access to the cockpit was recorded for one second. It was followed by the cockpit call signal from the cabin, known as the cabin call, from the cabin on four occasions. Over the next 15 minutes muffled voices were heard several times asking for the door to be opened, followed by noises similar to violent blows on the cockpit door, which were recorded on five occasions.
Between 09:38:38 and 09:39:23, an air traffic controller from the French Air Defence system tried to contact the flight crew on three occasions on 121.500 MHz, without any answer. A French Air Force Mirage jet was scrambled from the Orange-Caritat Air Base at 09:48, after having been ordered to do so by the national centre of aerial operations at 09:41. Also at 09:39:54, the flight crew of another aeroplane tried to contact the flight crew of D-AIPX, but again got no answer.
At 09:41:06, the CVR recording stopped at the moment of the collision with the terrain, which resulted in the fragmentation of aircraft. The wreckage was spread over an area of 4 hectares in a sloping rocky ravine with the largest remaining parts of the aircraft being about 3 to 4 metres long. The reported concluded that the violence of the collision with the terrain caused the immediate death of all the aircraft’s occupants. The Mirage sent to intercept the aircraft, flew over the vicinity of the accident site at 10:01. At around 10:15, the Marseille en-route control centre informed the BEA of the probable loss of the Airbus A320, and a team of seven investigators from the BEA travelled to the accident site that afternoon. With helicopter transport provided by the Gendarmerie, the safety investigators were able to access the site the following day.
Final Report contains 11 safety recommendations
Andreas Lubitz had been flying for Germanwings since June 2014 and was the holder a class 1 medical certificate. It was first issued in April 2008 and had been revalidated or renewed every year. Since July 2009, this medical certificate had contained a waiver because of a severe depressive episode, without psychotic symptoms, that had lasted from August 2008 until July 2009. This waiver stated that it would become invalid if there was a relapse into depression.
In December 2014, approximately five months after the last revalidation of his class 1 medical certificate, the co-pilot started to show symptoms that could be consistent with a psychotic depressive episode. He consulted several doctors, including a psychiatrist on at least two occasions, who prescribed anti-depressant medication.
He did not contact any Aero-Medical Examiners (AME) between the beginning of his decrease in medical fitness in December 2014 and the day of the accident.
In February 2015, a private physician diagnosed a psychosomatic disorder and an anxiety disorder and referred the co-pilot to a psychotherapist and psychiatrist. On 10th March 2015, the same physician diagnosed a possible psychosis and recommended psychiatric hospital treatment. A psychiatrist prescribed anti-depressant and sleeping aid medication in February and March 2015.
Neither of those health care providers informed any aviation authority, nor any other authority about the co-pilot’s mental state. Several sick leave certificates were issued by these physicians, but not all of them were forwarded to Germanwings. On the day of the accident, the pilot was still suffering from a psychiatric disorder, which was possibly a psychotic depressive episode and was taking psychotropic medication. This made him unfit to fly.
The report concludes that no action could have been taken by the authorities and/or his employer to prevent him from flying on the day of the accident, because they were informed by neither the co-pilot himself, nor by anybody else, such as a physician, a colleague, or family member. In addition, security requirements which led to cockpit doors designed to resist forcible intrusion by unauthorised persons, made it impossible to enter the flight compartment before the aircraft impacted the terrain in the French Alps.
The report also recognised that 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, it suggests that 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 report notes that he paid €60,000 to finance his part of the costs of his training at LFT and had taken out a loan for about €41,000 to do so. A Loss-of-License (LOL) insurance contracted by Germanwings existed and this would have provided him with a one-time payment of €58,799 in case he had become permanently unfit to fly in the first five years of employment. He did not have any additional insurance that would cover for potential future loss of income in case of unfitness to fly. In an e-mail he wrote in December 2014, he mentioned that having a waiver attached to his medical certificate was hindering his ability to get such an insurance policy;
- The lack of clear guidelines in German regulations on when a threat to public safety outweighs the requirements of medical confidentiality.
The investigation has led to the issuance of 11 safety recommendations by the BEA addressed to the World Health Organisation (WHO), the International Air Transport Association (IATA), the European Commission, the European Aviation Safety Agency (EASA), BMVI, the German Federal Ministry of Transport and Digital Infrastructure and the Bundesärztekammer (BÄK), the German Medical Association, relating to:
- medical evaluation of pilots with mental health issues;
- routine analysis of in-flight incapacitation;
- mitigation of the consequences of loss of licence;
- anti-depressant medication and flying status;
- balance between medical confidentiality and public safety;
- promotion of pilot support programmes.
The 11 safety 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. [Recommendation FRAN-2016-011].
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. [Recommendation FRAN-2016-013].
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. [Recommendation FRAN-2016-014].
IATA encourages its Member Airlines to implement measures to mitigate the socio-economic risks related to pilots’ loss of licence for medical reasons. [Recommendation FRAN-2016-015].
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. [Recommendation FRAN-2016-016].
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. [Recommendation FRAN-2016-017].
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. [Recommendation FRAN-2016-018].
Without waiting for action at EU level, the BMVI and the 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. [Recommendation FRAN-2016-019 and FRAN-2016-020].
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. [Recommendation FRAN-2016-021].
The BMVI appointed a task force to determine what conclusions could be drawn from the crash and it concluded in relation to cockpit doors that:-
- No changes be made over the short term to the locking system of the cockpit door.
- The cockpit and cabin crew must maintain a high level of safety awareness at all times, especially with regard to the careful execution of the applicable access procedures and avoiding opening the door/leaving the cockpit unnecessarily. It is recommended that the respective aviation companies conduct regular awareness campaigns on this point.
- Structural options (locks between cabin and cockpit door, WC installation in the protected area) should be examined over the long term when new aircraft are being developed.
- It was feasible to implement the ‘Two person’ rule on short notice in all German airline companies (the right to give the final decision on opening the door remains in the cockpit).
- The ‘Two person’ rule increases safety. Any additional risks can be compensated by taking concurrent measures. These measures are being continuously re-assessed in day-to-day operations. Experiences gathered during operation of the ‘Two person’ rule should be evaluated after the rule has been in place for one year. By way of contrast, the professional associations/pilot and flight attendant unions suggest on the basis of their overall assessment that the ‘Two person’ rule could be abolished.
As usual, and in line with our editorial policy the above report does not contain opinions, speculations or comment and is based solely on the published report. We also note that the English version of the report is a courtesy translation by the BEA and as accurate as the translation may be, the original text in French is the work of reference. For further coverage, we again refer you here to the Aviation Herald’s coverage, where Simon Hradecky continues to manage the information on an ongoing basis in a dispassionate and balanced way.