On March 24th,
2015 an Airbus A320-211 registered D-AIPX operating as Germanwings Flight 9525 (4U9525)
with scheduled service from Barcelona, Spain to Dusseldorf, Germany crashed into
a remote mountainside in the French Alps, killing all 150 people on board. Bureau d’Enquêtes et d’Analyses (BEA), the
investigative agency responsible for the accident, later confirmed, with chilling
unsettling reality, findings revealing that the co-pilot, A. Lubitz,
deliberately flew the airliner into the ground by act of murder-suicide.
Reverberations of shock
were felt sharply around the world after such unexpected revelation of the tragedy. The landmark catastrophe brought probing
scrutiny upon the aviation industry’s standards and practices. Vigorous debate arose in the public sphere of
the mainstream media and throughout the aviation industry alike; specifically regarding
pilot mental health and fitness of duty and rights of personal medical confidentiality
versus those of the flying public’s assurance of safety. It was however widely agreed upon that
industry changes were in order.
Lubitz’s medical history
revealed that recurring mental health issues had affected their flight training
and career progression over the course of years. Of which, most were self-reported per regulation
requirements of pilot medical certification, followed as result by medical
treatment and rehabilitation for compliance. Lubitz was declared fit for duty and approved
medical certification after each successful treatment of self-reported issue. However, it was found that Lubitz was not
always forthright in their full disclosure of medical issues as was required for
their continued medical certification to fly.
This may have been likely due to professional stigma, fear of medical disqualification
from their pilot career, and the financial loss and hardship of which would likely
result.
In fact, Lubitz
received multiple diagnoses and prescriptions by multiple treating physicians for
mental health issues in the weeks leading up to the crash. BEA’s final report of the crash revealed
Lubitz’s multiple issuances of sick leave certificates, referral for
psychiatric hospital treatment due to a possible psychosis, and multiple pharmaceutical
drug prescriptions for treatment of depression, anxiety, and sleep disorder – of
which, none were forwarded to Germanwings by Lubitz (BEA, 2016, p. 32). The physicians were fully aware of Lubitz’s unfit
condition for duty; the airline however was not, due partly to medical
confidentiality laws. Furthermore, outward
signs of such unfitness were not noticeably detected by Germanwings company or
crew. By industry self-reporting standards
Lubitz was deemed to have been legally fit for duty and safe to fly on that
fateful day.
The tragedy of
Germanwings 4U9525 unfortunately followed an uncannily similar tragedy less
than two years earlier. On November 29th,
2013 an Embraer ERJ 190-100 registered C9- EMC operating as LAM Mozambique
Airlines Flight 470 (LAM 470) with scheduled service from Maputo International
Airport, Mozambique to Luanda, Angola crashed into the remote scrub and brush land of Bwabwata National Park in
Namibia, killing all 33 people on board.
It would not be farfetched to hypothesize that Lubitz may have studied
this accident before enacting such similar effect themselves.
The Republic of Namibia,
Directorate of Aircraft Accident Investigation (DAAI): Civil Aircraft Accident
Report: ACCID/112913/1-12 published on April 5th, 2016 contained details
that all too closely resembled a precursory play by play of Lubitz’s 4U9525
murder-suicide:
Probable Cause: 1. The
inputs to the auto flight systems by the crew member believed to be the Captain
who remained alone in the cockpit when the person believed to be the co-pilot
requested to go to the lavatory, caused the aircraft to depart from cruise
flight to a sustained controlled descent and subsequent collision with the
terrain.
Contributing factors: 1. The
non-compliance to company procedures that resulted in a sole crew member occupying
the flight compartment.
Human Factors: 1.18.3 The investigation team also discovered
through the interview (family members and friends of the two pilots) that the
captain went through numerous life experiences ranging from: a) The
separation from the first wife of which the divorce process had not been
dissolved to almost (10) years after separation. b) The
death of a son who passed away in a car accident on a suspected suicide on the
21st of November 2012.
c) The captain was reported as
not to have attended his son’s funeral.
d) The captain’s youngest
daughter underwent heart surgery in one of the hospitals in South Africa not
long time ago (DAAI, 2016).
The
DAAI full report supported by evidence recovered from the flight data and
cockpit voice recorders validated probable cause to be of murder-suicide by
pilot.
One
of a generally average understanding and capacity for reason could infer that
the LAM 470 captain experienced considerable emotional upsets in their personal
life. Mental health issues were likely
the most probable cause leading up to the captain’s action of deliberately
flying the airliner into the ground.
These tragedies bear incredibly disturbing semblances and both such have
pleaded the questions, “How could this have been prevented? Where did the system of safety fail?”
The
threat to flight safety pre 9/11 attacks was assumed to be coming from the
passenger side of the flight deck door and not from within the flight deck
itself. In order to mitigate the deadly
actions of a single bad actor, as was the case with LAM 470, the aviation
industry widely adopted “2-person in the cockpit” regulations following the 4U9525
déjà vuesque tragedy. The “2-person in
the cockpit” regulation is very much akin to the “Two-Person Concept” implemented by the
United States Air Force (USAF) Nuclear Weapons and Systems Surety program. An excerpt from USAF Airforce Instruction
91-104 publication defines their mutual accountability concept similarly (USAF,
2017):
The
Two-Person Concept (TPC) is central to nuclear surety tamper control measures
in the Air Force. It is designed to make
sure that a lone individual cannot perform an incorrect act or unauthorized
procedure on a nuclear weapon, nuclear weapon system, or certified critical
component (USAF, 2017).
Simply
speaking – actions by a sole individual can never be guaranteed free of risk,
but risk can be greatly reduced through established procedures of mutual
accountability.
The
USAF has been successfully using this TPC failsafe method for quite a while. Thus far, the skies have yet to be filled by
an apocalyptic world threating volley of intercontinental ballistic missiles
between thermonuclear warhead superpower flexing state actors. However, according to the January 25th
published, “2018 Doomsday Clock Statement” from the Bulletin of the Atomic
Scientists, “It is now two minutes to midnight—the closest the Clock has ever
been to Doomsday, and as close as it was in 1953, at the height of the Cold War”
(Mecklin, 2018).
Of
course, one bad actor could still be capable of overpowering their counterpart from
within the system of safety of which they’re both entrusted.
What
protects the flying public from mentally ill pilots? In 2016 the Federal Aviation Administration
(FAA) published their Factsheet – Pilot Mental Fitness to provide some clarity (FAA,
2016):
How
does an Aviation Medical Examiner (AME) assess mental health?
The
FAA medical application form includes questions pertaining to the mental health
of the pilot. An AME may ask questions
about psychological conditions as part of his/her assessment. Pilots must
disclose all existing physical and psychological conditions and medications or
face significant fines if they are found to have falsified information. They must report any health professional
visits during the previous three years. The
AME will use this self-disclosure to ask additional questions about mental
health issues. The AME can order
additional psychological testing, or defer the application to the FAA Office of
Aerospace Medicine if he or she is concerned that further evaluation is
necessary.
Additionally,
if the FAA receives information from another source that a pilot may have a
mental health issue, the FAA's Office of Aerospace Medicine can direct the
pilot to provide specific documentation and/or a psychiatric and psychological
evaluation from a mental health care professional in order to make a
determination about the pilot's suitability for certification.
If
a pilot experiences an incident that appears medically related, the FAA will
request additional medical information to determine the eligibility of the
pilot to hold a medical certificate. If
an FAA flight surgeon determines that a pilot with a valid medical certificate
no longer meets the medical standards, the flight surgeon will then recommend
that FAA counsel revoke or suspend the medical certificate.
Certain
medical conditions such as a psychosis, bipolar disorder and severe personality
disorder automatically disqualify a pilot from obtaining an FAA medical
certificate and prohibit them from flying. However, many pilots have conditions that are
treatable. Several U.S. airlines already
have reporting and monitoring programs that provide the pilot with a path to
report their condition, be treated for it, and return to the cockpit once the
FAA has determined – through a rigorous evaluation – it is safe to do so. The FAA addresses the medical certificates of
those pilots on a case-by-case basis.
The
FAA does not release medical records on living pilots, including the results of
any pilot’s medical testing, because medical information is covered by privacy
laws (FAA, 2016).
The
above excerpt is relatively short and sweet when compared to the comprehensive
FAA Pilot Fitness Aviation Rulemaking Committee (ARC): Pilot Fitness ARC Recommendation
Report (FAA, 2015). The FAA ARC Charter was
created following the events of Malaysia Airlines Flight 370 (MH370) mysterious
disappearance on March 8th, 2014 and the Germanwings Flight 9525 (4U9525)
murder-suicide tragedy of which brought the topic of pilot mental health to the
forefront of contemporary concerns.
For
those with deeper interests on the broad reaching topics of pilot mental
fitness, the full FAA ARC is recommended reading. Yet, the Environmental Health article by Wu
et al. (2016), titled “Airplane pilot mental health and suicidal thoughts: a
cross-sectional descriptive study via anonymous web-based survey,” may pique a greater
considerable interest on the topic with its intimately “living” subject matter
compared to majority of other studies focused on the “dead.” Their extensive study wraps with this fitting
excerpt:
Poor
mental health is an enormous burden to public health worldwide. The tragedy of Germanwings flight 4U 9525
should motivate further research into assessing the issue of pilot mental health.
Although current policies aim to improve
mental health screening, evaluation, and record keeping, airlines and aviation
organizations should increase support for preventative treatment (Wu et al.,
2016).
In
conclusion: Pilot mental illness issues have a long way to go before society
could be seen as to having a healthy outlook on their management. It is widely purported that a segment
within the pilot population exists, which actually needs treatment for their
mental health wellness, yet will not actually seek such treatment for risking
jeopardy of their career livelihood. A punitive
regulatory environment in the aviation industry will clearly exacerbate problems
of non-reporting by those truly affected by mental illness. The effect of such an environment persisting may
only serve to weaken the flying public’s safety and security from future
incidents; of which otherwise could be averted if the climate were changed.
Unfortunately,
the wheels of law, regulation, and social acceptance grind ever so slowly
toward their much needed changes.
– Aviator in Progress
References
BEA.
(2016). Final Report: Accident on 24
March 2015 at Prads-Haute-Bléone (Alpes-de-Haute-Provence, France) to the
Airbus A320-211 registered D-AIPX operated by Germanwings. Bureau
d’Enquêtes et d’Analyses pour la sécurité de l’aviation civile. Retrieved from https://www.bea.aero/uploads/tx_elydbrapports/BEA2015-0125.en-LR.pdf
DAAI.
(2016). Republic of Namibia: Ministry of
Works and Transport: Directorate of Aircraft Accident Investigation: Civil
Aircraft Accident Report: ACCID/112913/1-12. Republic of Namibia: Ministry
of Works and Transport. Retrieved from http://www.iacm.gov.mz/doc/AIG/RelatorioTM470.pdf
FAA.
(2016). Fact Sheet – Pilot Mental Fitness:
June 9, 2016. Federal Aviation Administration. Retrieved from https://www.faa.gov/news/fact_sheets/news_story.cfm?newsId=20455
FAA.
(2015). Pilot Fitness Aviation Rulemaking
Committee Report: November 18, 2015. Federal Aviation Administration.
Retrieved from https://www.faa.gov/regulations_policies/rulemaking/committees/documents/index.cfm/document/information/documentID/2762
Mecklin,
J. (2018). It is 2 minutes to midnight:
2018 Doomsday Clock Statement. Bulletin of the Atomic Scientists. Retrieved
from https://thebulletin.org/sites/default/files/2018%20Doomsday%20Clock%20Statement.pdf
USAF.
(2017). Air Force Instruction 91-104.
United States of America: Department of the Air Force. Retrieved from http://static.e-publishing.af.mil/production/1/afmc/publication/afi91-104_afmcsup/afi91-104_afmcsup.pdf
Wu
et al. (2016). Airplane pilot mental
health and suicidal thoughts: a cross-sectional descriptive study via anonymous
web-based survey. Environmental Health. Retrieved from https://doi.org/10.1186/s12940-016-0200-6
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