Quote:3 - CONCLUSIONS
3.1 Findings
General findings
..the aeroplane had a valid Certificate of Airworthiness;
..A review of the FDR and CVR data brought to light no aircraft system failures or faults that could have contributed to the accident;
..the aeroplane’s maintenance documentation did not mention any system failures that were incompatible with the flight as planned;
..the flight crew possessed the licences and ratings required to perform the flight;
..the co-pilot obtained his class 1 medical certificate without restrictions in April 2008, valid for one year;
..a depressive episode and the taking of medication to treat it delayed the renewal of the copilot’s class 1 medical certificate between April and July 2009;
..from July 2009, the co-pilot’s medical certificate was endorsed with the note « Note the special conditions/restrictions of the waiver FRA 091/09 -REV-»;
..the co-pilot’s MPL(A), issued in February 2014, was endorsed with the remark "***SIC**incl. PPL***";
..the co-pilot class 1 medical certificate was regularly revalidated or renewed from 2010 to 2014 at the Lufthansa AeMC. All the AMEs who examined him during that period were aware of the waiver FRA 091/09 and his history of depression;
..the waiver FRA 091/09 neither included the requirement for regular specific assessments by a psychiatrist nor reduced the time in-between two assessments;
..his last class 1 medical examination took place on 28 July 2014;
..no psychiatrist or psychologist was involved in the copilot’s class 1 medical certificate revalidation/renewal process after the issuance of the waiver FRA 091/09;
..the co-pilot had a loss of licence insurance that would have given him a one-time payment of about 60,000€ which corresponds approximately to his pilot training expenses, but he did not have any additional insurance covering the risk of loss of income resulting from unfitness to fly;
..peer support groups are available to Germanwings pilots.
Findings relevant to the period between December 2014 and the day of the accident
..the copilot suffered from a mental disorder with psychotic symptoms;
..anti-depressant and sleeping aid medication was prescribed to the co-pilot;
..the co-pilot did not contact any AME;
..no record was found that the co-pilot sought any support from peers;
..the co-pilot went on flying as a commercial pilot carrying passengers;
..the mental state of the co-pilot did not generate any reported concern from the pilots who flew with him;
..a private physician referred the co-pilot to a psychotherapist and psychiatrist one month before the accident and diagnosed a possible psychosis two weeks before the accident;
..the psychiatrist treating the co-pilot prescribed anti-depressant medication one month before the accident and other anti-depressants along with sleeping aid medication eight days before the accident;
..no health care providers reported any aeromedical concerns to authorities;
..no aviation authority, or any other authority, was informed of the mental state of the co-pilot.
Findings relevant to the first flight of the day of the accident (from Düsseldorf to Barcelona)
..the aircraft took off from Düsseldorf at 6 h 01;
..several altitude selections towards 100 ft were recorded during descent on the flight that preceded the accident flight, while the co-pilot was alone in the cockpit;
..the aircraft landed in Barcelona at 7 h 57.
Findings relevant to the second flight of the day of the accident (from Barcelona to Düsseldorf)
..the aeroplane took off from Barcelona bound for Düsseldorf at 9 h 00, with flight number 4U9525, and callsign GWI18G;
..the autopilot and autothrust were engaged during the climb;
..the Captain left the cockpit at the beginning of the cruise at FL380;
..the selected altitude changed from 38,000 ft to 100 ft while the co-pilot was alone in the cockpit. The aeroplane then started a continuous and controlled descent on autopilot;
..during the descent, the Marseille control centre called flight GWI18G on eleven occasions on three different frequencies, without any answer being transmitted;
..the French military defence system tried to contact flight GWI18G on three occasions during the descent, without any answer;
..the buzzer to request access to the cockpit sounded once during the descent, 4 min 07 s after the Captain had left;
..the intercom sounded in the cockpit, 4 min 40 s after the Captain had left;
..three other calls on the interphone sounded in the cockpit;
..none of the calls using the interphone elicited any answer;
..noises similar to violent blows on the cockpit doors were recorded on five occasions;
..the cockpit doors of the aircraft are designed for security reasons to resist penetration by small arms fire and grenade shrapnel and to resist forcible intrusions by unauthorized persons;
..an input on the right sidestick was recorded for about 30 seconds on the FDR 1 min 33 s before the impact, not enough to disengage the autopilot;
..the autopilot and autothrust remained engaged until the end of the CVR and FDR recordings;
..the sound of breathing was recorded on the CVR until a few seconds before the end of the flight;
..before the collision with the terrain, warnings from the GPWS, Master Caution and Master Warning sounded;
..the aeroplane collided with the terrain at 9 h 41 min 06.
3.2 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.
4 - SAFETY RECOMMENDATIONS
Note: in accordance with the provisions of Article 17.3 of Regulation No. 996/2010 of the European Parliament and of the Council of 20 October 2010 on the investigation and prevention of accidents and incidents in civil aviation, a safety recommendation in no case creates a presumption of fault or liability in an accident, serious incident or incident. The recipients of safety recommendations report to the authority in charge of safety investigations that have issued them, on the measures taken or being studied for their implementation, as provided for in Article 18 of the aforementioned regulation.
Due to the strong interdependency between matters related to the aeromedical certification of pilots, and matters related to the assistance to pilots in situations where there is risk of loss of licence, the following safety recommendations should be viewed as a single comprehensive package, and should be implemented together. Treating them in isolation, or implementing only part of them, could be counter-productive and would not generate the expected safety benefits.
4.1 Medical evaluation of pilots with mental health issues
Mitigation of the risks that pilot in-flight incapacitation represent to flight safety relies on the presence of a second pilot to take over all flying duties in the event of incapacitation of the other pilot. Mental incapacitation can make this principle fail, in particular when one pilot decides to purposely put the aircraft into an unsafe condition. This accident and other similar events identified during the investigation, including some with two crew members in the cockpit, illustrate this failure. Consequently, mental incapacitation should not be treated in the same way as physical incapacitation and a more stringent target for detecting potentially unsafe mental disorders should be targeted. Most aeromedical experts consider that in depth psychological testing to detect serious mental illness is inappropriate and that testing for psychological disorders as part of the routine periodic pilot aeromedical assessment is neither productive nor cost effective. However, it might be useful to regularly evaluate the mental health of pilots with an identified history of mental illness.
Identifying pilots who would require additional psychiatric evaluation would be improved if AMEs received additional training in mental health issues in aviation. This additional training has been already recommended by the AsMA Expert WG, UK DfT/CAA WG, BMVI WG, and the EASA Task Force.
The short time between the discontinuation of the medication and the issuance of the first medical certificate with a waiver may not have offered all the tangible elements to confirm that the mental state of the pilot was fully stabilised in July 2009. From 2010 to 2014, and in compliance with EU regulations, the co-pilot revalidated or renewed his class 1 medical certificate, which contained a limitation related to his past depressive episode, without any additional specific psychiatric evaluation.
Consequently the BEA recommends that:
€€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]
4.2 Routine analysis of in-flight incapacitation
Currently available data does not provide accurate awareness of in-flight incapacitation risks, especially in relation to mental health issues. This lack of data, confirmed by the difficulties experienced during the investigation in collecting data on previous similar incidents or accidents, can be explained by the reluctance to report this type of event, by the lack of investigations being carried out, by ongoing judicial proceedings, and/or restrictions linked to medical confidentiality.
ICAO recommends that States should, as part of their State Safety Programme, apply basic safety management principles to the process of medical assessment of licence holders, to include as a minimum:
ˆˆa) routine analysis of in-flight incapacitation events and medical findings during medical assessments to identify areas of increased medical risk; and
ˆˆb) continuous re-evaluation of the medical assessment process to concentrate on identified areas of increased medical risk.
The Network of Analysts defined in article 14.2 of EU regulation 376/2014 may provide an appropriate forum for gathering and assessing data on medical risks at the EU level.
Consequently the BEA recommends that:
€€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. [Recommendation FRAN-2016-012]
€€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]
4.3 Mitigation of the consequences of loss of licence
The co-pilot was aware of the decrease in his own medical fitness and of the potential impact of his medication. However, he did not seek any advice from an AME, nor did he inform his employer. One of the explanations lays in the financial consequences he would have faced in case of the loss of his licence. His limited Loss of License insurance could not cover his loss of income resulting from unfitness to fly. More generally, the principle of self-declaration in case of a decrease in medical fitness is weakened when the negative consequences for a pilot of self-declaration, in terms of career, financial consequences, and loss of self-esteem, are higher than the perceived impact on safety that failing to declare would have.
Organisations, especially airlines, can reinforce self-declaration of a decrease in medical fitness of their staff, by acting on some of the consequences of unfitness, by offering motivating alternative positions and by limiting the financial consequences of a loss of licence, for example through extending loss of licence coverage.
Consequently the BEA recommends that:
.€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 encourage 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]
4.4 Anti-depressant medication and flying status
The co-pilot did not seek any advice from an AME nor did he inform his employer in spite of his ongoing depression and associated medication.
In Germany, as in most European countries, depression is a clear reason for declaring a pilot to be unfit to fly. There is evidence of depressed professional pilots refusing medication because they would be grounded if they did so. There is also evidence of pilots taking anti-depressant medication without declaring it to aeromedical authorities, while continuing to fly.
ICAO recommends that pilots with depression, being treated with antidepressant medication, may be assessed as fit to fly if the medical assessor considers the applicant’s condition as unlikely to interfere with the safe exercise of the applicants licence and rating privileges. Similarly, (EU) regulations state that after full recovery from a mood disorder, if stable maintenance psychotropic medication is confirmed, a fit assessment should require a multi-pilot limitation. Some National Aviation Authorities allow aircrew to continue to fly while taking specific medication to treat depression. Such programs exist in Australia, the UK, Canada and the USA. The modalities differ between countries but all include specific medical assessment, a list of accepted medication (among selective serotonin reuptake inhibitors named SSRI), whose possible side effects have been shown to be compatible with flying duties, clinical reviews and requirements for mental stability before being allowed to return to flying duties. Authorising controlled medication ensures that pilots can be monitored more closely. It reinforces self-declaration by allowing pilots to declare any depression without fear being grounded for an excessively long time. This counteracts the possibility that pilots might choose, if left to their own devices, to fly while depressed, with or without adapted medication. However, even if allowed by EU regulations, not all European countries have clearly-established policies and technical guidance for the use by pilots of anti-depressant medication.
Consequently the BEA recommends that:
.€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]
4.5 Balance between medical confidentiality and public safety
Medical confidentiality is a key principle in ensuring trust between doctors and patients. The fact that people are encouraged to seek advice and treatment, with the guarantee that their personal information will be kept confidential, benefits society as a whole as well as the individual. However, the public interest may also be served by disclosing information to protect individuals or society from risks of serious harm. Personal information should, therefore, be disclosed in the public interest even without patients’ consent, if the benefits to an individual or to society of the disclosure outweigh both the public and the patient’s interest in keeping the information confidential. The investigation has shown that provisions allowing health care providers to breach medical confidentiality exist in most States, in particular in Europe, under certain conditions and when it is in the interest of preserving public safety or preventing imminent danger. EU regulations authorize the processing of medical data if it is required for the purpose of medical diagnosis and if the person processing the data is under an obligation of secrecy. Some States have dedicated provisions applying to pilots whose health issues need to be reported to the relevant authorities if they threaten public safety. Other States, like Germany, have only general provisions applying to any citizen and to any imminent danger. In those States, such provisions are regularly outweighed, in the decision process of doctors, by provisions related to medical confidentiality, which are perceived as more important and which contain possible legal consequences if they are violated.
Furthermore, the absence of a formal definition of "imminent danger" and "threat to public safety" drives doctors to adopt a conservative approach and may lead them not to report their potential concerns to authorities.
The investigation has shown that a private physician referred the co-pilot to a psychotherapist and psychiatrist one month before the accident and diagnosed possible psychosis two weeks before the accident. It also showed that the psychiatrist treating him prescribed anti-depressant medication one month before the accident and other anti-depressants, along with sleeping aid medication, eight days before the accident. None of these health care providers reported any aeromedical concerns to authorities. It is likely that breaching medical confidentiality was perceived by these doctors as presenting more risks, in particular for themselves, than not reporting the co-pilot to authorities.
Combining the guarantee of knowing the occupation of their patients who are pilots, with regulations allowing and/or mandating health care providers to inform authorities in case pilot unfitness threatens public safety, would create an environment favourable for doctors to report to authorities. The various questions relating to the balance between public good and confidentiality favour a global approach that addresses every area of concern, in order to provide better protection for all parties (the patient, the doctor, the public). It is therefore important that evolutions in the regulations address the overall issue of medical confidentiality, but also the risks that pilots・ health issues may pose to public safety. Recommendations about the appropriate balance between patient confidentiality and the protection of public safety have already been made by the AsMA Expert WG, UK DfT/CAA WG, and the EASA Task Force.
Consequently the BEA recommends that:
€€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 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 [Recommendation FRAN-2016-019 and FRAN-2016-020]
4.6 Promotion of pilot support programmes
The investigation has shown that in spite of the onset of symptoms that could be consistent with a psychotic depressive episode and the fact that he was taking medication that made him unfit to fly, the co-pilot did not seek any aeromedical advice before exercising the privilege of his licence. This is likely the result of difficulties in overcoming the stigma that is attached to mental illness, and the prospects of losing his medical certification and therefore his job as a pilot. Self-declaration in case pilots experience a decrease in medical fitness or starting a regular course of medication can be fostered if psychological support programs are available to crews who experience emotional or mental health issues. Existing programs, overseen by peers, provide a "safe zone" for pilots by minimizing career jeopardy as well as the stigma of seeking mental health assistance. These programs are sometimes underutilized for reasons such as: employees questioning the confidentiality of the service; the perception that a stigma is attached to asking for professional help with personal matters; or lack of unawareness of the program and its capabilities. Management of a decrease in medical fitness can be optimized by including the intervention of peers and/or family members. AsMA recommends extending awareness of mental health issues beyond the physician to facilitate greater recognition, reporting and discussion. Peer support systems are well implemented in major airlines, particularly in North America, where just culture principles are well known. However, these types of systems may pose significant implementation challenges when they are applied to smaller sized organisations that are less mature and have a different cultural background. For these peer support groups to be efficient, crews and/or their families need to be reassured that mental health issues will not be stigmatized, concerns raised will be handled confidentially and that pilots will be well supported, with the aim of allowing them to return to flying duties. The promotion of pilot support programs has already been recommended by AsMA Expert WG, UK DfT/CAA WG, BMVI WG, and the EASA Task Force.
Consequently the BEA recommends that:
€€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]
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