GERMANWINGS 9525 REVISITED By David Keen, Log Board member In March 2015, a young pilot crashed in a remote part of the French Alps, killing all the passengers and crew on board. Four years on, it is worthwhile reviewing what happened – and what may T be concluded from this terrible event his was not the first time we had witnessed a dramatic murder-suicide in aviation, though set against the billions of passenger journeys safely undertaken each year, it is still extraordinarily rare. At least five more notable occurrences involving large passenger numbers have taken place in the past 25 years. They have involved individual pilots operating for Egyptair, Silk Air, Royal Air Maroc, LAM Mozambique, and almost certainly Malaysian Airlines. Unlike these episodes, both the CVR and FDR were recovered from the A320 wreckage. Both devices were sufficiently intact to allow a detailed investigation, involving both French and German aviation authorities, with cooperation from the FBI and Airbus. The first officer who caused the crash was Andreas Lubitz, a 27-year-old former Lufthansa cadet with 630 hours total time. His actions involved locking the captain out of the cockpit and subsequently establishing the jet into a high-speed descent to a pre-set altitude of 100ft amsl, in the direction of a mountainous region of south- west France. During the descent, Lubitz made repeated actions to keep the flight-deck door locked from the inside, and remained calm and in control of the Airbus, making use of the autopilot the whole time. His recorded breathing patterns were calm, and he made no effort to leave his seat and unlock the door, precluding the theory that the door- unlocking mechanism was jammed. The criminal investigators learned that Lubitz had experienced a severe depressive episode during initial flight training in 2009, and had been grounded for several months. Following recovery, he re-joined and completed his training in 2010. He worked as long-haul cabin crew for two years, and then joined Germanwings as a first officer flying the A320 in short-haul European operations. Suicidal ideation Detailed examinations of the contents of Lubitz’s bedroom/office, including the memories on his laptop and tablet, revealed that the first officer had experienced a major relapse in the form of a severe psychotic episode that started around Christmas 2014. He had been receiving treatment for this up until the crash three months later, consulting numerous medical specialists in Germany. Unfortunately, the airline and his aviation medical examiners were unaware of this major issue, which would undoubtedly have led to Lubitz being grounded, probably permanently. He had, in fact, expressed suicidal ideation on several occasions, and had been issued with sick notes from a range of doctors; Lubitz kept these notes, did not submit them, and continued to fly when he had been instructed not to work at all. The rules of medical confidentiality in Germany prohibit doctors from reporting medical issues of patients to their employers, and even to their medical experts. This situation still holds today, and not only in Germany. One key reason for confidentiality is liability, whereby loss of a job or career can bring about litigation for substantial compensation on behalf of the patient. However, although German privacy laws are generally restrictive, they do allow psychiatrists to notify relevant parties (including an employer) if they believe the patient may present a danger to the lives of others. In this case, Lubitz’s hometown psychiatrist did nothing, despite being fully aware of his profession. She has not responded to any requests for information from the media. The immediate media reaction to the dramatic crash and its build up was hysterical and inaccurate in many cases. The co-pilot was reported to be 17 years Germanwings Airbus A320 approaching Zurich Airport in 2013. The aircraft crashed near Digne, France, on 24th March 2015 THE PROFILE OF THIS MAN DOES NOT PARALLEL THAT OF A VENGEFUL, HOMICIDAL PSYCHOPATH old in a British tabloid, and Piers Morgan trumpeted that “it was a disgrace for a man with acute depression to be allowed to fly”. Therein lies the issue of mental health of this pilot. Major depressive disorder affects approximately one in six men. About 50% of those who recover will experience one or more relapses. Lubitz started with psychosomatic symptoms, consulting and being tested by ophthalmologists and neurologists. He complained consistently of seeing stars, halos, and suffering from light sensitivity and double vision. Some doctors suggested that he was hypochondriacal; others that he, in fact, had psychotic symptoms. He abandoned treatment at this point. His GP READ MORE How to get help diagnosed ‘emergent psychosis’ and recommended psychiatric treatment. At first, Lubitz ignored this advice. He was also suffering from chronic sleeplessness, common enough among many healthy pilots, but debilitating nonetheless. In January 2015, at the insistence of his mother, Lubitz returned to the same psychiatrist who treated him for nine months back in his initial training period of 2009/2010. He was again prescribed heavy-duty psychotropic drugs, namely lorazepam and mirtazapine. The former is a powerful sedative, the latter an antidepressant. Lubitz continued to fly while taking these. His torment with insomnia was reported in a diary he kept, whereby three to four hours’ sleep was considered a triumph. Online search By March 2015, Lubitz had been searching for means of suicide online. His laptop and tablet memories showed he had researched many different approaches, and two days prior to the crash, he reviewed the door-locking mechanism on the A320. He would have been familiar with this at user-level, but the young pilot was presumably concerned that it could be disengaged from outside the cockpit. A note, apparently written to himself the day before the crash, was entitled ‘Decision Sunday’, which referred to BCN (the return flight to Barcelona) and to a number of possible courses of action: “find the inner will to work and continue to live”, “deal with stress and sleeplessness”, and “let myself go”. Perhaps clues existed before this, but this note summarises the dilemma that Lubitz faced. Mystery remains Was Lubitz a textbook narcissist, a man driven to suicide by rage over his illnesses, real or imaginary? The profile of this man does not parallel that of a vengeful, homicidal psychopath. He had a close relationship with his girlfriend, was close to his parents and grandparents, and also sustained normal friendships. He had no known grievances with colleagues or superiors. So, what could explain this premeditated killing, this callous indifference to all the men, women, and children whose lives he took? Why commit mass homicide instead of a lone suicide? These are mysteries and will doubtless remain so. Depression of the intensity experienced by Lubitz, with its overwhelming feelings of worthlessness and failure, can overwhelm all rational thinking and decision making. Couple that with the torture of chronic sleep deficiency and one can identify a psychotically depressed person barely able to function on the inside, but outwardly in full control. Identifying such determined individuals early may be close to impossible. Psychological checks can be unreliable, and crude. At best, a high proportion of healthy individuals could be grounded permanently, based upon current test methodologies. The sensitivity of psychological examinations does not permit accurate selection of those extremely rare people like Lubitz. Pilots are driven people, with strong will and determination. One hopes that the present system of initial and recurrent medical checks will identify those experiencing a much lower level of anxiety or depression – and it is vital that the follow-up to diagnosis is not perceived as punitive and, possibly, career- finishing. MENTAL HEALTH GERMANWINGS 9525 REVISITED By David Keen, Log Board member READ MORE How to get help Are you struggling to cope with stress, anxiety, depression or any other form of mental health issue? Contact your Company Council for details of your airline’s peer support programme, or click for details of our Pilots’ Advisory Group. Alternatively, you can call The Samaritans on 116 123, or visit Mind’s website at www.mind.org.uk for tips on coping with mental health. If you are worried that you or someone you know is in immediate danger, call 999.