On 24 March 2015, flight GWI18G operated by Germanwings with an airbus A320, carrying 150 people on board crashed in the foothills of the French Alps. The plane, carrying young people, vacationers and others, was flying from Barcelona to Düsseldorf. It crashed after an eight-minute descent from 38,000 feet. Everyone on-board sadly died.
According to Regulation (EU) 996/2010 [4], the French Aviation Investigation Body (BEA) has initiated a formal safety investigation. The initial readout of the Cockpit Voice Recorder showed that the co-pilot Andreas Lubitz locked himself into the cockpit alone taking advantage of the temporary absence of the Pilot-in-Command (PiC), Patrick Sonderheimer, due to physiological needs. From that moment on, Lubitz stopped speaking and no longer allowed the PiC enter the cockpit. The co-pilot deliberately set the autopilot to automatically descend to an altitude of 100 feet (about 30 metres) and thereafter, on several occasions during the descent, the co-pilot modified the autopilot setting to increase the speed of the airplane along the track, as confirmed by initial findings obtained from the Flight Data Recorder. Lubitz was still alive until impact with the ground, so any temporary incapacitation due to physical causes is excluded.
Investigators are continuing their work to establish the precise history of the flight, but the preliminary findings already confirm that Lubitz’s actions on the flight controls can only have been deliberate. So, Lubitz committed suicide. Based on this, it has been surmised that Lubitz suffered from depression. Such a possibility has been reinforced by the fact that anti-depression medication was found in Lubitz’s home. Furthermore, there was evidence that Lubitz had undergone psychiatric treatment in specialised centres in the past.
Hence, the event appears to be a case of murder-suicide, which is very different from a simple suicide from the psychopathological perspective and extremely rare, especially outside domestic contexts.
In fact, in these sad situations, one person wishing to end her/his life takes the lives of others – in this case, complete strangers – at the same time. The elements that are confirmed so far, for example the fact that Lubitz locked himself into the cabin, suggest a premeditated action. This would seem to indicate a narcissistic or paranoid attitude rather than depression. In fact, the co-pilot behaved under a precise and long-matured thought, then acted driven by impulse, erasing from his mind all other concerns, including his responsibility for the lives of other crewmembers and passengers.
In this light, the Germanwings accident could be seen as a result of an intentional violation of rules and procedures conceived to cause damage, where the planned action (violation) achieves the outcome (damage) desired by the author. Hence, this type of behaviour does not constitute human error [3] and, following investigation, could be considered an act of sabotage (maybe associated to psychopathological issues).
In recent aviation history, there are at least four cases where the suicidal intention of one of the two pilots has lead to the crash of an airliner and the death of everyone on-board. The oldest case dates back to 21 August 1994, when an ATR42 of Royal Air Maroc crashed on the ground in the vicinity of Agadir and 44 people died. Moroccan authorities ascertained, based on CVR listening, that the accident was due to the suicidal intention of the 35 year-old pilot. In fact, the audio of the last 30 minutes of the flight revealed that he screamed he wanted to die.
On 19 December 1997, in Indonesia, a Boeing 737-300 operated by Silk-Air crashed on the Sumatra Island and 104 people died. The Indonesian investigation authority concluded that the accident was deliberately caused by the PiC, who wanted to commit suicide. Also in this case, the CVR provided sufficient evidence, revealing also the struggle by the co-pilot in trying to take control of the aircraft.
Again, on 31 October 1999, a Boeing 747 operated by EgyptAir crashed into the sea near the American coast of New England. All 217 people on-board died. The USA National Transport Safety Board (NTSB), competent as State of Occurrence per ICAO Annex 13, established that no technical failure was among the causal factors of the accident, which instead originated from a deliberate action by the pilot.
More recently, on 29 October 2013, flight TM470 with 27 passengers and 6 crew members on-board crashed while flying over Botswana. The investigation, even in this case, revealed that the pilot had deliberately led the plane to crash.
There are several other recorded events, albeit of lesser severity. Cases of air disasters due to pilots’ or passengers’ suicide are collected in the database of the Aviation safety network http://aviation-safety.net/database/dblist.php?Event=SES.
Now, the question is how safety against the hazard related to psychopathological issues can be ensured. In other words, how fit for duty of crew is assessed also from this perspective and whether current rules are sufficient.
Often in aviation, safety hazards are addressed through hardware and software solutions (i.e. technology) or through procedures. Through hardware (sensors of weight on pilot positions, modifications to doors) or procedures (crew always composed of two pilots), hazards can indeed be mitigated; but no hardware solution can mitigate the risk of a scuffle in the cockpit, which was part of at least two of the aforementioned accidents. On 27 March 2015, EASA published a temporary recommendation for airlines to ensure that at least two crew members, including at least one qualified pilot, should be in the flight crew compartment at all times during the flight. Airlines need to re-assess the safety and security risks associated with a flight crew member leaving the cockpit due to operational or physiological needs. Fine: all this enhances safety.
But, is this enough to ensure fitness for duty? One should perhaps read the current EASA part-MED [1] where it addresses the requirements for class 1 pilot’s medical certificates. In particular, AMC1 MED.B.055 “Psychiatry” includes psychotic disorders, organic mental disorders, use or abuse of psychotropic substances, schizophrenia and mood disorders as totally or partially disqualifying. Regarding personality or behavioural disorders, the regulation states “where there is suspicion or established evidence that an applicant has a personality or behavioural disorder, the applicant should be referred for psychiatric opinion and advice”. But no guideline is given on how and when assessment has to be performed. AMC1 MED.B.060 “Psychology” is also included in the medical conditions to assess the fitness for duty of cabin crew, and states that pilots should undergo psychological assessment only when specific indicators are detected in their anamnesis. However, even when psychological assessment is deemed necessary, currently no rule exists which establishes repeating it on a periodic basis. Thus, these tests are not repeated according to a standard consolidated praxis, but are only used ad hoc on a case-by-case basis, when a particular need is detected.
But ensuring on-going fitness for duty – physically, cognitively and emotionally – is one of the most crucial aspects in aviation safety, while emotional issues also can play a debilitating role on the flight line, in the dispatcher’s office or on board the aircraft. Quay Snyder, MD, president and CEO of the Aviation Medicine Advisory Service stated: “Up to 25 per cent of the population suffers emotional disorders during their lifetime. People can certainly be successfully treated”. He added: “But the challenge is that people in aviation, pilots in particular, who tend to be a stoic group, refuse to acknowledge such a problem or seek help. We have to educate them to conquer their reluctance and get help when needed” [5]. Even ICAO is slowly recognising the relevance of emotional fitness, at least in its recent RPAS Manual [2], which describes the notion of “competence” as not only “to know” (theoretical knowledge) and “to know how” (practical skill) but also “to behave” (= psychological aspects).
Indeed the problem has been widely investigated in the nuclear sector, resulting in detailed consolidated programmes to assess fitness for duty, also from a psychological point of view, of nuclear facility personnel [6] based on the standards provided by the American Psychology Association.
The author hopes that this direction will be followed up by the definition of standard psychological assessment and monitoring programmes also in the aviation field, to be specified both at regulation and at praxis level.
Reference:
- European Aviation Safety Agency (EASA), Acceptable Means of Compliance and Guidance Material to part-MED,15 December 2011 http://www.seguridadaerea.gob.es/media/4343660/amc_and_gm_on_the_medical_certification_of_pilots_and_medical_fitness_of_cabin_crew.pdf
- ICAO Doc 10019 AN/507 (2015) Manual on Remotely Piloted Aircraft Systems http://www.dronezine.it/wp-content/uploads/2015/03/10019_cons_en-Secured-1.pdf
- Reason J. (1990), Human error. New York: Cambridge University Press
- Regulation (EU) 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 and repealing, Directive 94/56/EC http://www.icao.int/SAM/SSP/Documents/EU%20Reg%20996-2010.pdf
- Snyder Q., Fitness for duty vital to successful business aviation operations, National Business Aviation Association press release of 14 April 2014, http://www.nbaa.org/ops/safety/20140414-fitness-for-duty-vital-to-successful-business-aviation-operations.php
- United States Nuclear Regulatory Commission, Personnel access authorization requirements for nuclear power plants, Part 73.56 point e http://www.nrc.gov/reading-rm/doc-collections/cfr/part073/part073-0056.html
