When you hear about a suicidal pilot, your mind might automatically jump to thinking of kamikazes. Unfortunately, this post refers to an airline suicidal pilot who tragically took his own life along with all the passengers and crew on board. This is the sad story of Germanwings 9525.
GermanWings 9525 Flight Card:
- Aircraft: Airbus A320-211
- Registration: D-AIPX
- Operator: GermanWings (Owned by Lufthansa Group)
- Callsign: GWI18G
- Persons on board: 2 Flight Crew, 4 Cabin Crew and 144 passengers.
- Survivors: Zero
- Date: 24 March 2015
- Time: 09:41 UTC
- Route: Barcelona (Spain) to Dusseldorf (Germany)
- Crash Site: The French Alps – France. Click here for the location (https://goo.gl/maps/D6umCYDQCQTRUKsR8)
Germanwings 9525 Flight:
Who was flying?
The first officer was the pilot flying (PF) for that leg, and the captain was the pilot monitoring (PM).
Flight Crew Information card & Experience:
Captain:
- Male, 34 years old, German.
- Total Flying Hours: 6,763 hours
- Total Flying Hours on Type (A320): 3,811 hours, 259 as a Captain.
- He undertook his training at Lufthansa Pilot School (Germany) and the airline training centre in Phoenix (USA). Afterwards, in 2005, he obtained his A320 type rating, worked as a co-pilot for five years, and then obtained his A340 type rating in 2010 and A330 type rating a year later in 2011. He worked from 2010 to 2014 as a co-pilot for Lufthansa on the Airbus A330/A340. Finally, in 2014, he joined Germanwings as a captain on the Airbus A320.
First Officer:
- Male, 27 years old. German.
- Total Flying Hours: 919 Hours.
- Total Flying Hours on type (A320): 540 hours.
- He undertook his training at Lufthansa Flight Training Pilot School (Germany); he then suspended his training for medical reasons and resumed it a year later. After passing his ATPL exams, he continued his training at the airline training centre in Phoenix (USA). He obtained his A320 type rating at Lufthansa in December 2013 and then joined Germanwings.
- He excelled during training and recurrent checks, with his performance rated above standard.
Aircraft Information:
- Entry into service: 05/02/1991
- Utilisation as of 24/03/2015: 58,313 hours and 46,748 cycles
- Engines type: CFM56-5A1
Maintenance:
The aircraft’s maintenance checks were up to date. The last maintenance performed on the aircraft took place on 23 March 2015 at DĂĽsseldorf Airport (1 day before the accident).
The Flight:
The flight took off from Barcelona at 09:00 from runway 07R. The aircraft then continued climbing to its cruising altitude of 38,000ft (FL380) and levelled off at 09:27. The flight crew were in contact with the Marseille en-route control centre and then transferred to another Marseille control centre frequency.
The ATC cleared Germanwings 9525 to fly directly to a point named IRMAR, to which the captain read back saying: “Direct IRMAR, Merci, Germanwings one eight Golf.”
At 09:30, the captain asked the co-pilot to take over radio communications as he needed to use the toilet.
At 09:30:53, the captain left, and the F/O was on his own. The selected altitude was changed from 38,000ft to the absolute minimum value that can be selected on the A320, which is 100ft, and the aircraft started to descend.
Three minutes later, the co-pilot adjusted the target speed to 308kt and then increased it to 323kt the following minute.
At 09:33:47, the controller asked the flight crew about their cleared cruise level, but the co-pilot did not respond. The controller continued calling throughout the flight, but the co-pilot remained silent.
The captain requested to enter the Cockpit, but the F/O didn’t open the door. He kept calling the Cockpit using the cabin interphone, but there was no reply. Violent blows on the cockpit door were recorded throughout all of this. The captain was trying to get in after he realised what was happening.
At 09:40:41, an aural warning from GPWS was active, ‘Terrain, Terrain, Pull Up, Pull Up,’ as the flight was heading towards the terrain.
At 09:41:06, Germanwings 9525 disappeared from the radar as the aircraft impacted the terrain in the French Alps.
Everyone onboard died with no survivors, and the aircraft was destroyed.
Investigation:
The Bureau of Enquiry and Analysis for Civil Aviation Safety (BEA) launched a comprehensive investigation into the crash of Germanwings 9525. The investigation began with the recovery and analysis of the Flight Data Recorder (FDR) and Cockpit Voice Recorder (CVR), which provided crucial insights into the final moments of the flight.
Initially, investigators considered several possible causes for the crash, including the potential for an onboard fire, a sudden cabin depressurisation, or the possibility that the co-pilot had become unconscious and was therefore unable to open the cockpit door.
However, the data retrieved from the FDR and CVR allowed the investigators to rule out these scenarios:
- Fire: The FDR and CVR showed no signs of smoke, fire alarms, or related abnormalities. The absence of any such alerts or communication about a fire led investigators to conclude that an onboard fire was unlikely.
- Cabin Depressurisation: The FDR data did not show any emergency descent consistent with a rapid depressurisation event, nor were there any corresponding alarms recorded. Additionally, there were no communications indicating an oxygen mask deployment or other depressurisation Non-normal procedures.
- Unconscious Pilot: The CVR revealed that the co-pilot was conscious and actively controlling the aircraft after the captain left the cockpit. The audio recordings revealed the co-pilot’s deliberate actions, including manual changes to the autopilot settings and the aircraft’s descent path, confirming that he was not incapacitated.
With these scenarios eliminated, investigators shifted their focus to the co-pilot’s actions and his medical history. This led them to explore the possibility that the crash was the result of a deliberate act, driven by the co-pilot’s mental health issues, which ultimately became the central focus of the investigation.
Medical history of the co-pilot:
Medical logs showed that he was depressed (We mentioned before that he discontinued training at Lufthansa for nine months); the reason was he was taking anti-depressants.
On 10/07/2009, The treating psychiatrist reported that the F/O was “entirely healthy” and “the treatment had ended”. After that, he was issued a restricted medical certificate.
On 18/06/2010, the FAA rejected his application for a third-class medical due to his history of reactive depression. The FAA required him to submit a report from his prescribing physician that included the diagnosis, prognosis without medication, follow-up plan, and copies of treatment records.. After he submitted the requested documents, the FAA reviewed them and subsequently issued him his third-class medical certificate
Between 2011 and 2014, he continued to receive renewals of his class 1 medical certificate, though with special restrictions.
In December 2014, he reported vision problems and sleeping disorders to his doctors.
36 days before the accident, he received an 8-day sick leave, which he did not forward to Germanwings.
16 days before the accident, he was issued a sick leave certificate with an unknown end date. This certificate was once again not forwarded to Germanwings.
15 days before the accident, he was referred for psychiatric hospital treatment due to a possible psychosis.
13 days before the accident, he was issued a sick leave for 19 days which he didn’t forward to Germanwings.
09 days before the accident, he got further prescriptions from his treating psychiatrist.
07 days before the accident, the co-pilot was put on sick leave for 5 days by a private physician.
He ended up visiting 24 different doctors and told them about the same problems he was having, but none of them contacted Lufthansa as they thought he would do that by himself.
An even darker truth:
On the first flight of the day (Dusseldorf to Barcelona), while the co-pilot was alone in the Cockpit, there were several altitude selections towards 100 ft that were recorded as well, meaning that the co-pilot had been planning the crash since the first leg.
Conclusions on Germanwings 9525:
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 following factors were mentioned in the final report:
- The co-pilot was afraid of losing his ability to fly as a pilot due to his medical fitness.
- The fear of the potential financial consequences due to the lack of insurance covering the risks of loss of income in case of losing his licence to medical unfitness.
- There is a lack of clarity in German rules about when public safety overrides medical confidentiality.
Aftermath – Change of Regulations:
A new regulation was introduced that would require airlines to have two crew members in the Cockpit at all times. So if a co-pilot, for example, has left to use the toilet, a flight attendant should be present inside the Cockpit with the captain, and the opposite applies. Even though this rule was dropped by EASA later on, it still seems to be the norm by most airlines.
Commemoration of GermanWings 9525:
A sculpture called “Sonnenkugel” was installed at the crash site of 4U9525 to commemorate the 149 victims of the 24 March 2015 tragedy.
Thank You Note:
I’d like to thank Lars Rollberg for kindly allowing me to use his picture of D-AIPX. Check out his website for quality aviation photography https://www.lars-rollberg.com
References:
BBC. (2015, March 27). Germanwings crash: Co-pilot Lubitz ‘hid illness’. BBC News. Retrieved March 23, 2022, from https://www.bbc.com/news/world-europe-32087203
BBC. (2015, May 6). Alps plane crash: What happened? BBC News. Retrieved March 22, 2022, from https://www.bbc.com/news/world-europe-32035121
Bureau d’Enquêtes et d’Analyses pour la sécurité de l’aviation civile. (2015, May). Preliminary report. Retrieved March 20, 2022, from https://www.bea.aero/fileadmin/uploads/tx_elydbrapports/d-px150324.en.pdf
Bureau d’Enquêtes et d’Analyses pour la sécurité de l’aviation civile. (2016, March). D-AIPX Presentation Presse. Retrieved March 20, 2022, from https://www.bea.aero/fileadmin/uploads/tx_elyextendttnews/2016_03_15_D-AIPX_Presentation_Presse_EN_06.pdf
Bureau d’Enquêtes et d’Analyses pour la sécurité de l’aviation civile. (2016, March). Final report. Retrieved March 20, 2022, from https://www.bea.aero/fileadmin/uploads/tx_elyextendttnews/BEA2015-0125.en-LR_10.pdf
Bureau d’Enquêtes et d’Analyses pour la sécurité de l’aviation civile. (n.d.). Presentation du rapport anglais. Retrieved March 21, 2022, from https://www.bea.aero/fileadmin/uploads/tx_elyextendttnews/Presentation_du_rapport_-_anglais_10.pdf
Clark, N., & Bilefsky, D. (2015, March 25). Germanwings pilot was locked out of Cockpit before crash in France. The New York Times. Retrieved March 21, 2022, from https://www.nytimes.com/2015/03/26/world/europe/germanwings-airbus-crash.html
Engel, P. (2015, March 27). Prosecutor: Germanwings co-pilot’s Doctor’s Note said he was ‘unfit to work’ before fatal crash. Business Insider. Retrieved March 22, 2022, from https://www.businessinsider.com/germanwings-co-pilot-andreas-lubitz-hid-illness-from-employers-2015-3
The New York Times. (2015, March 24). What happened on the Germanwings Flight. The New York Times. Retrieved March 21, 2022, from https://www.nytimes.com/interactive/2015/03/24/world/europe/germanwings-plane-crash-map.html
Rollberg, L. (2014). D-Aipx, Germanwings, Airbus A320-211, cn 147. photograph, Berlin-Tegel Airport. Retrieved March 28, 2022, from https://www.lars-rollberg.com/ap/14642/
Hersman, D. (2015, March 27). The chilling final moments of Germanwings Flight 9525. NPR. Retrieved March 23, 2022, from https://www.npr.org/sections/thetwo-way/2015/03/27/395734630/the-chilling-final-moments-of-germanwings-flight-9525
International Civil Aviation Organization (ICAO). (2016). Annex 13 to the Convention on International Civil Aviation: Aircraft Accident and Incident Investigation (10th ed.). Retrieved March 23, 2022, from https://www.icao.int/Meetings/a39/Documents/Doc%209908_en.pdf
Williams, R. (2015, March 27). Germanwings crash: Why did no one notice Andreas Lubitz was unfit to fly? The Guardian. Retrieved March 22, 2022, from https://www.theguardian.com/world/2015/mar/27/germanwings-andreas-lubitz-crash-why-no-one-notice-unfit
