Germanwings accident final report published

Accident to the Airbus A320-211, registered D-AIPX and operated by Germanwings, flight GWI18G, on 03/24/15 at Prads-Haute-Bléone.

N° BEA2015-0125.en

Synopsis

Deliberate flight into terrain

Germanwings A320 Alps

Photo (C) Dejan Milinkovic – Pixstel Photography Airliners.net

Aircraft Airbus A320-211 registered D-AIPX
Date and time 24 March 2015 at 09 h 41(1)
Opertor Germanwings
Place Prads-Haute-Bléone (04)
Type of flight Commercial Air Transport Revenue operations, Passenger
Persons on board Captain (PM), co-pilot (PF), 4 cabin crew, 144 passengers
Consequences and damage Crew and passengers fatally injured, aeroplane destroyed

The co-pilot had been flying for Germanwings since June 2014 and was the holder a class 1 medical certificate that 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. The co-pilot 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 10 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.

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 the cruise phase of the accident flight, the co-pilot waited until he was alone in the cockpit. He then intentionally modified the autopilot settings to order the aeroplane to descend. He kept the cockpit door locked during the descent, despite requests for access made via the keypad and the cabin interphone. He did not respond to the calls from the civil or military air traffic controllers, nor to knocks on the door. Security requirements that led to cockpit doors designed to resist forcible intrusion by unauthorized persons made it impossible to enter the flight compartment before the aircraft impacted the terrain in the French Alps.

The BEA investigation concluded 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. The following factors may have contributed to the failure of this principle:

..the co-pilot’s probable fear of losing his right 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.

The BEA has addressed eleven safety recommendations to the WHO, IATA, the European Commission, EASA, BMVI and BÄK 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.

To download the complete final report (French, German, English and Spanish) go to the BEA site Accident to the Airbus A320-211, registered D-AIPX and operated by Germanwings, flight GWI18G, on 03/24/15 at Prads-Haute-Bléone.

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minime2By Laura Victoria Duque Arrubla, a medical doctor with postgraduate studies in Aviation Medicine, Human Factors and Aviation Safety. In the aviation field since 1988, Human Factors instructor since 1994. Follow me on facebook Living Safely with Human Error and twitter@dralaurita. Human Factors information almost every day 

 

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