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Mental health lessons for rail from Germanwings 9525

Chris Langer, scheme intelligence manager at CIRAS, the confidential incident reporting and analysis system, on what the rail industry can learn from the tragic Germanwings 9525 crash.

When 34-year-old Captain Patrick Sondenheimer took the controls of Germanwings flight 9525 on 24 March 2015, nothing could have prepared him for the terrifying situation he would face on the scheduled flight from Barcelona to Dusseldorf. 

Sondenheimer had 10 years’ flying experience under his belt. To spend more time with family, he had recently switched from long-haul flights at parent company Lufthansa to short-haul flights at Germanwings. 

His co-pilot was 27-year-old Andreas Lubitz who had a history of mental illness and was suffering with psychotic symptoms. 

As it happened 

The Airbus 320 takes off from Barcelona at 09:01 GMT and begins travelling over the sea towards France. It takes about half an hour to climb to the cruising altitude of 38,000ft. 

Lubitz is initially courteous towards Captain Sondenheimer, but reportedly becomes a little ‘curt’ when the captain gives the mid-flight briefing on the planned landing. With the benefit of hindsight, that is perhaps the only inkling of what is to come. 

At 09:30 the plane has its final contact with air traffic control – just a routine communication about permission to continue on its route. The captain informs Lubitz he is leaving the cockpit, most probably for a toilet break, and asks him to take over radio communications. The cockpit door is heard opening and closing on the voice recorder. 

Seconds later, Lubitz seizes the opportunity to manually put the aircraft into descent from 38,000ft to 100ft. The plane begins plummeting through the sky at nearly 4,000ft a minute. 

Air traffic controllers try to contact the pilots from 09:33 onwards, but are met with no response. Lubitz does not say a word, though his breathing remains normal. Noises similar to a person knocking on the cockpit door can be heard. There are then some muffled voices, followed by a request for the cockpit door to be opened.  

Despite repeated attempts by crew members and air traffic control to get Lubitz to respond, nothing works. Noises similar to violent blows on the cockpit door are recorded on five instances in the last 90 seconds of flight. 

The ‘Terrain, Terrain, Pull Up, Pull Up’ warning is sounded around 30 seconds before the final impact at 09:41. Passengers can be heard screaming only near the very end. 

The plane crashes into the French Alps at 430mph at the hands of one suicidal pilot – death is instant for all 144 passengers and the six members of crew.

Findings from the safety investigation 

The French Civil Aviation Safety Investigation Authority, BEA, produced a final report of its findings in March this year. But it is by no means easy to see how a tragedy like this could be prevented in the future, even after their thorough investigation and insight into the causes. 

The immediate cause of the crash was Lubitz’s decision to commit suicide while alone in the cockpit. He had effectively hidden a psychiatric condition which made him unfit to fly. His mental state in the months leading up to that fatal day went unnoticed by the pilots that flew with him. He had not sought any support through pilot support programmes available to Germanwings pilots, such as the well-established Mayday Foundation designed to help those experiencing personal difficulties. 

The BEA concluded that: “No action could have been taken by authorities and/or his employer to prevent him flying that day, because they were informed by neither the co-pilot himself, nor anybody else, such as a physician, a colleague, or family member.” 

This goes right to the heart of the matter. How can an accident like this be prevented where the information required to intervene is not available to the authorities in the first place? 

A similar scenario is in fact faced by the authorities in trying to prevent a terrorist attack on the public by a lone gunman. Without the availability of reliable intelligence, it is extremely difficult to take pre-emptive action. It is especially difficult if the perpetrator goes to great lengths to hide the threat he poses to the public. 

Lubitz started to show symptoms possibly associated with a psychotic depressive episode in December 2014. This was five months after the last revalidation of his class 1 medical certificate required for airline pilots to exercise their license. He consulted various doctors, and was prescribed anti-depressant medication by the psychiatrist treating him. 

EU regulations stipulate that pilots should seek the advice of an Aero Medical Examiner (AME) after starting the regular use of medication. Lubitz, however, neglected to tell any AMEs and continued to fly until the day of the accident. 

In February 2015, he consulted a private physician, who diagnosed a possible psychotic depressive episode, and referred him to a psychotherapist and psychiatrist. A month later, just two weeks before the accident, the same physician was concerned enough to recommend psychiatric hospital treatment.

A history of depression 

Lubitz’s mental health problems can be traced further back. He dropped out of his training in November 2008 to be treated by a psychiatrist who prescribed medication. In July 2009, the depressive episode was declared over. Lubitz had recovered. His class 1 medical certificate was issued, but with a waiver stating it would be invalidated if there was any relapse into depression. 

All the AMEs who examined him between 2010 and 2014 were aware of his medical history of depression. Their professional evaluations of his psychological fitness deemed him fit to fly when Lubitz presented himself. His class 1 medical certificate was therefore revalidated on each occasion without the need for further examination. 

One could argue that, given Lubitz’s history of depression, more extensive psychiatric evaluations should have occurred in the interests of protecting the public. However, the BEA contacted specialists in aerospace medicine and psychiatrists who generally agree that: “Detection tools and methods can remain ineffective in cases where the patient is intentionally hiding any history of mental disorder and/or is faking being in good health. This is why most believe that putting in place extensive psychiatric evaluation as part of routine aeromedical assessments of all pilots would not be productive or cost effective.” 

It is acknowledged, though, that in the case of individuals with a history of mental illness the evaluation process could be strengthened. 

Grounds for breaking confidentiality? 

None of the health professionals involved in Lubitz’s treatment reported any public safety concerns to the authorities. Believing in the universally accepted principle of medical confidentiality, they upheld the trust between doctor and patient, as would be expected. 

Those treating him will probably have been aware that he was a pilot. They could have reported their concerns, at least in theory. What stopped them? German regulations contain provisions to punish doctors breaching medical confidentiality, including possible imprisonment of up to a year. There was no formal definition of ‘threat to public safety’ to guide them, and the fear of being sued for passing on private medical information may have weighed heavily on their minds. 

The balance between medical confidentiality and public safety is clearly a delicate one. In hindsight, it appears the balance was skewed in favour of medical confidentiality to the detriment of public safety. However, simply changing the regulations to allow for breaches of medical confidentiality under certain circumstances might have unfortunate side effects. 

For example, if you were a pilot, and aware your doctor could breach your medical confidentiality, would you be inclined to be so candid about your mental health? A Kafkaesque element might creep in, possibly driving the expression of mental health issues further underground, increasing the stigma attached. Perhaps allowing doctors to pass on medical information anonymously may provide part of the solution, but this is not without its pitfalls either. 

What we can learn from the accident 

The ultimate cause of the Germanwings accident was a distressed individual no longer in touch with reality. One cannot underestimate the stigma attached to his mental illness. The potential consequences for his career, and life, if Lubitz could no longer fly probably felt insurmountable to him. 

It would be complacent to assume such an accident couldn’t happen in the rail industry. It would be advisable for every rail organisation to assess the safety risk posed by an individual in such a state of mind. Early interventions should be considered wherever possible. The questions that will need answering are: 

• Is the organisation confident that they will be able to detect a sick or unfit employee who poses a risk to public safety? If detected, how will this risk be effectively managed?
• Do current EAPs (Employee Assistance Programmes) provide robust enough support for staff with long-term mental health difficulties?
• How can we reduce the stigma attached to mental illness in the workplace for rail workers?
• Could we learn anything from the airline industry’s mental health support programmes for pilots? Similar schemes could be adopted more widely in the rail industry 

To fully address the stigma attached to mental illness will no doubt require some organisational soul-searching. If we are truly interested in the health and wellbeing of rail workers, and public safety, such an effort promises to mitigate the associated risks.

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