Germanwings case and the
EASA Task Force
Matti Sorsa 2015
Germanwings 9525
24 March 2015
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Since 1980
6 Accidents. - 423 Fatalities.
29 November 2013 – LAM Flight 470 – Embraer ERJ-190 – 33 Fatalities
31 October 1999 – Egypt Air Flight 990 – Boeing 767 – 217 Fatalities
11 October 1999 – Air Botswana – ATR 42 – 1 Fatality
19 December 1997 – Silk Air Flight 185 – Boeing 737 – 104 Fatalities (Unconfirmed)
21 August 1994 – Royal Air Maroc Flight 630 – ATR 42 – 44 Fatalities (Unconfirmed)
9 February 1982 – Japan Airlines - DC8 – 24 Fatalities:
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EASA
• Transport Commissioner, Ms Violeta Bulc tasked EASA to create a task
force following the accident of Germanwings flight 4U9525 on 24
March 2015.
Objective
• The aim of the task force is to prepare high-level recommendations in
the fields of pilot medical monitoring, operational mitigation
measures, and other related subjects considered relevant by the task
force, aiming at the prevention of future accident and incidents.
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Task Force Members
Alain Bassil, COO, Air France
Patrick Cipriani, Director for Civil Aviation Safety, DGAC France
Filip Cornelis, Head of Unit – Aviation Safety, European Commission DG MOVE
Dr. Sally Evans, Chief Medical Officer, UK CAA
Andrew Haines, Chief Executive, UK CAA
Pekka Henttu, Director General, Finnish Transport Safety Agency (TRAFI)
Marc Houalla, President, École Nationale de l’Aviation Civile (ENAC)
Kay Kratky, COO, Lufthansa
Patrick Ky, Executive Director, EASA
Prof. Dr. Helmut Landgraf, Aeromedical Center Vivantes Klinikum
Paul Reuter, Technical Director, European Cockpit Association
Matti Sorsa, Chief Psychologist, Pilot Select Oy
Geoff Want, Director Safety and Security, Easyjet
Dr. Elizabeth Wilkinson, Head of Health Services, British Airways
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TASKS
1. The application of the 2-persons-in-the-cockpit rule
2. The assessment of pilots
3. AME qualifications and training, recurrent examination,
and process oversight:
4. The electronic cockpit door lock system
5.Creating an EU repository for medical data
6.Creating a socially responsible culture/environment for
pilots
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Recommendation 1:
• The Task Force recommends that the 2-persons-in-the-cockpit
recommendation is maintained. Its benefits should be evaluated after
one year. Operators should introduce appropriate supplemental
measures including training for crew to ensure any associated risks
are mitigated.
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2. Psychological evaluations for initial pilot
selections – the basis (MS)
• Evaluation of applicants for airline pilot training
(self-sponsored vs. state/airline sponsored) is
essential. Airline entry selection is also necessary
(except perhaps in the case of MPL)
• Both of the above shall be done using shall be done
with aviation psychological expertise assured by the
training organisation and airline respectively
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Aeromedical (MS)
• Aeromedical examination plays a less role in this risk
management
• It is unreasonable – and unfair - to assume that an
AME should evaluate the pilot’s mental condition
during a short meeting
• In case any doubt exists from any source the AME
should be able to use psychological/psychiatric
expertise for consultations and possible referrals
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Initial C1 Medical Assessment
• General mental health assessment ‘appearance/ speech/ mood/
thinking/ perception/ cognition/ insight/ signs of alcohol or drug
misuse’
• Heavily reliant on history given by applicant
• May lead to referral for psychiatric or psychological review
• No ‘screening’ tests for psychiatric disorders exist (reporting of
symptoms = disorder present)
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Recurrent Aeromedical Assessments
• Aeromedical assessment and advice in between medicals is essential
component
• Guidance material needed in Part MED eg. on the acceptable level of
incapacitation risk
• Fit and proper person: concerning/criminal behavior
Note
• increasing tests likely to adversely affect flight safety by taking time
that should be directed to clinical assessment.
• trusting relationship with AME is key
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European Society of Aerospace
Medicine (ESAM)
• More rules wont solve the ‘GW’ problem.
• A change in culture is required. Across the spectrum.
• AME should not work in isolation, needs good relationship with
AMS and ideally other AMEs
• Computerized records essential. It is the 21st century. Pilot tourism
is a reality. Central database of ‘unfit’ or special conditions.
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ESAM
Confidentiality IS NOT THE SAME as secrecy.
• ‘Bolt on’ psychological/psychiatric questionnaires likely to be an
impediment.
• Detection of dishonesty is difficult, especially at ‘fit and proper’
level.
• Research is needed to improve the tools of psychosocial
assessment. Note ‘psychosocial’
• AME training. QA of initial. Adequacy of refresher…20hrs/3 years.
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Recurrent psychological assessments and
safeguards
• No recurrent psychological test system is feasible
(time factor, reliability)
• Recurrent psychological testing is not necessary –
operational surveillance is continuous and covers
both training and line work. Simulator checks reveal
performance variations and raise questions of
psychological/neurological problems.
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Recommendation 2:
• The Task Force recommends that all airline pilots should undergo
psychological evaluation as part of training or before entering service.
The airline shall verify that a satisfactory evaluation has been carried
out.
• The psychological part of the initial and recurrent aeromedical
assessment and the related training for aero-medical examiners
should be strengthened. EASA will prepare guidance material for this
purpose.
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Recommendation 3:
• The Task Force recommends to mandate drugs and alcohol testing as
part of a random programme of testing by the operator and at least in
the following cases:
- initial Class 1 medical assessment or when employed by an airline,
- post-incident/accident,
- with due cause, and
- as part of follow-up after a positive test result.
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Recommendation 4:
• The Task Force recommends the establishment of robust oversight
programme over the performance of aero-medical examiners
including the practical application of their knowledge.
• In addition, national authorities should strengthen the psychological
and communication aspects of aero-medical examiners training and
practice.
• Networks of aero-medical examiners should be created to foster peer
support.
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4. Cockpit door lock – no recommendation
- ICAO Annex 6 requires a “secure” cockpit door
- ORO (ORGANISATION REQUIREMENTS FOR AIR OPERATIONS) .SEC.100 Flight crew compartment security: Lockable door required if more than 60
pax. or 45.5t
- ORO.SEC.100 (c)(2) Monitor the area in front of the cockpit door from
either pilot station.
- FAR 129.28 Flight deck security applicable to foreign operators.
- CS 25.795 requires a secure flight deck door if required by operating
rules.
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5. Creating an EU repository for medical data
• Data protection vs Safety: the legal landscape
• How it is ensured in EASA rules
• Implementation in by Member States
• Specific issue of medical data: collection, retention, sharing
• Links to other EU and/or national rules
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The Task Force reviewed the feasibility of a European
aeromedical data repository containing basic medicoadministrative information and of a comprehensive
aeromedical records management system to supersede
national systems.
The practicality of implementing a full pan-European
aeromedical records management system at this time
was questioned.
- cost,
- lengthy implementation time,
- data security and
- difficult buy-in from stakeholders.
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A European repository containing medico-administrative
information, limited to Class 1 medicals, would deliver a
significant benefit and be more readily accepted by aeromedical examiners and other stakeholders.
- basic personal information (name, date of birth),
- State of License Issue (or to which the pilot has applied for a
medical certificate if yet to achieve a licence) and
- details of the aero-medical examiner who issued the last
medical certificate and current fit status. (While
acknowledging the limitations of the repository, it could as
an act as interim measure to a future full aeromedical
records system.)
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Recommendation 5:
• The Task Force recommends that national regulations ensure that an
appropriate balance is found between patient confidentiality and the
protection of public safety.
• The Task Force recommends the creation of a European aeromedical
data repository as a first step to facilitate the sharing of aeromedical
information and tackle the issue of pilot non-declaration. EASA will
lead the project to deliver the necessary software tool.
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6. The operational work environment
• Pilot operates within a team, not only in the cockpit, but during
courses, simulators... No airline pilot works alone (vs. many other
safety-related professions)
• Highly proceduralized work with checklists, call outs where deviation
from the norm may be easily noted.
• Regular checking and training throughout the year
• LOFT, Line Checks, interactive “class room” CRM may help to detect
issues early on
• Last resort, reporting systems (confidential or not) in
case of unresolved perceived safety issues during a flight.
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What we need to avoid:
• Undue additional burden on the pilot by introducing additional
stressors like regular psychological testing
• Jeopardizing the mutual trust that crew needs among themselves and
towards their organization to be able to take safety relevant decisions.
• Creating an atmosphere of anxiety and paranoia where any personal
trait or behavior will be looked at and scrutinized.
• Taking measures that drive pilots with mental issues underground due
to fear for their livelihood
• Throwing Just Culture principles out of the window
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Potential risks
• If some sort of routine psychological/psychiatric
evaluation were included in the recurrent medical
examination there is a real danger of false findings that
end people’s careers unnecessarily and create massive
legal problems
• If operators do not promote openness and do not offer
proper channels for psycho-social support there is a risk
that pilots cover their normal life problems
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Legal issues and authorities
• If authorities are ready to redraw licenses even when pilot
has a natural life problem (such as divorce) which causes a
temporary life crisis there is a risk that pilots do everything
to conceal their problems
• If information about pilot’s mental state problems does not
reach operators and authority for national legal reasons the
safety net fails
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Proposals for improvement (1)
• The initial selection (to ATP training and to an
airline) is the key factor in the risk management –
this shall be done professionally and using stringent
criteria
• During pilot’s career continuous monitoring of
pilot’s behaviour and performance variations by the
employer and colleagues is essential
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Proposals for improvement (2)
• All operators shall ensure that their safety culture is open
and fair so that pilots can trust the employer and reveal
their training, operational and life problems without fear
of losing their jobs and they should have access to psychosocial support when needed
• All these aspects should be required to be included in the
operator approved SMS
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Proposals for improvement (3)
• In case information about pilot’s problems is
available (to an AME, other medical doctors,
pilot’s colleagues, his superiors etc.) national
legislation should be examined to see whether
for legal reasons this information does not reach
the employer or the authorities early enough to
enable corrective actions
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Recommendation 6:
• The Task Force recommends the implementation of pilot support and
reporting systems, linked to the employer Safety Management System
within the framework of a non-punitive work environment and
without compromising Just Culture principles. Requirements should
be adapted to different organisation sizes and maturity levels, and
provide provisions that take into account the range of work
arrangements and contract types.
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Finally (MS)
• The Germanwings case was an extremely rare a case and does not
justify new and drastic measures.
• The aviation industry risk management system when applied as
described above covers all reasonable risks
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Finally (MS)
• The most important element is the initial selection that is done
properly. After that the normal airline training and operational
practices cover the risk sufficiently if employers are assuming their
responsibility and can offer professional treatment channels to pilots
• The authorities should require this to be included in their approved
SMS.
• Operators (Airlines) should promote a fair and open culture where
pilots can discuss their problems such as training issues, family
problems etc. without fear of losing their jobs and they should have
access to psycho-social support when needed
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Way Forward
• Task Force proposes that EASA is tasked with the production of an
action plan for the implementation of the recommendations
stemming from this report. This should include a prioritisation of
actions considering cost and time factors.
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Action Plan (7Oct2015)
• Global Aircrew Medical Fitness workshop 2015 loppuun mennessä
• Lukuisia kv-organisaatioita (IATA, IFALPA; EFT; IACA, ESAM etc.)
• Concept paper for consultations
Operational Directives 2016 alussa => implementations (NAA’s), AMC+GM’s
Follow-up in standardisation meetings (inc. The use of of the European
aeromedical repository)
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