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6 Aug, 2015

Germanwings crash probe report highlights impact of stress, alcohol and drugs on those at the controls

Bangkok — Two investigation reports into the March 24 crash of Germanwings flight have underscored the role of stress, alcohol and drugs (S.A.D.) on the mental condition of pilots. By extension, they have raised serious concerns about the influence of S.A.D. on the mental condition of those at the wheel of all modes of transport, or in fact in any decision-making capacity.

Safety and security is the overarching concern of the entire travel/tourism/transportation sector. Be they bus or locomotive drivers, cruise-ship captains or any other means of mass transit and transport, those at the controls have the lives of hundreds of passengers and commuters in their hands. The Germanwings investigation proved that 144 passengers and six crew members all perished at the hands of one mentally imbalanced pilot. A European Aviation Safety Agency (EASA) report says clearly: “The BEA preliminary report (by the French Civil Aviation Safety Investigation Authority, Bureau d’Enquetes et d’Analyses), concluded that the accident was caused by an intentional act from the co-pilot to down the aircraft. The report also highlighted areas which should be looked at in more depth in order to help prevent the recurrence of such events.”

The keywords here are: “Looked at more in depth.” There is no limit to the depth one can go in scrutinising the report.

On the surface, the EASA report (which is the one analysed in this dispatch) flags the vast imbalance between the safety and security sides of transportation. To provide security from external threats, passengers are being forced to bear the cost of installing vast amounts of equipment and waste inordinate amounts of time to be checked for a range of potentially harmful material and equipment. However, the EASA report proves that an equally serious threat, largely overlooked, is internal. No X-ray machine can detect the mental disequilibrium of those at the wheel. While billions of dollars and man-hours are being spent to avert the former, very little is known about what is being done to address the latter.

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Click on the image to download the report.

The report reveals a little known fact: “From 1980 to 2011, there were 31 medical-cause commercial air transport accidents of which 20 were of psychiatric cause. The highest proportion of the psychiatric causes (60%) was due to drugs or alcohol.”

It states unequivocally, “Drugs and alcohol can lead to errors, slow or incorrect judgment and decisions, poor cognitive function, slow reaction times, mood changes, poor coordination, tracking or concentration and risk-taking behaviour or inappropriate action. All these have clear implications for flight safety. In contrast to most other medical causes of flight crew impairment or incapacitation, the impairment of a pilot due to drugs and alcohol is often difficult to recognise and is likely to affect the whole of a flight duty period. Side effects from certain types of medication can also lead to a flight safety risk.”

While drugs and alcohol would be classified as being in the realm of aero-medical issues, the report notes that psychiatric and psychological problems are another potential can of worms.

It says, “Pilots, like other professionals, are susceptible to the effects of stress or negative personal situations and may sometimes be hesitant to seek help and support for a number of reasons. The obvious stressors include the work environment, psychosocial hazards such as fatigue and workplace or private problems, time pressure and stress sources all adults must deal with. This combination of factors may lead to temporary mental health issues or, if not recognised and treated, possible permanent issues.”

Indeed, the report is not just an air-crash probe but has a far greater value than its immediate scope. Every day, millions of people place their lives in the hands of decision-makers across all spectrums of society whom they know nothing about. Just like the Germanwings pilot, their mistakes can jeopardise lives. Does the public have a right to know whether those decision-makers are under extreme stress or otherwise influenced by alcohol and drugs? This editor would say: Yes, indeed it does.

Germanwings flight 9525 was en route from Barcelona–El Prat airport in Spain to Düsseldorf Airport in Germany. According to the report, the Airbus A320-200 crashed in the French Alps, some 100 kilometres northwest of Nice, after a constant descent that began shortly after the aircraft had reached its cruise altitude. Further details can be read here: https://en.wikipedia.org/wiki/Germanwings_Flight_9525#Andreas_Lubitz

Global Pilots Association rejects further

psychological/psychiatric evaluations

On August 5, the International Federation of Airline Pilots Association (IFALPA) rejected the suggestion of further extensive psychological/psychiatric evaluations beyond those already required in the pre-employment testing process.

A position statement issued by IFALPA said anything further “is neither productive nor cost effective and therefore not warranted.” It added: “Routine psychological/psychiatric evaluation is a gross invasion of privacy and may impose more stress, threat and anxiety on the individual. Not all tests are culturally valid and screening tools are unreliable. Mental health assessment will only create the illusion of safety enhancement.”

Click on the image below to download the full IFALPA statement.


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An investigation report compiled by a Task Force led by the European Aviation Safety Agency (EASA) was released publicly in Brussels on 17 July 2015. Violeta Bulc, EU Commissioner for Transport said, “The safety of European citizens is at the heart of the Commission’s transport policy and today’s report is a valuable contribution. If improvements are to be made in the European safety and security rules or in their implementation, in order to help prevent future accidents or incidents, we will take the necessary action at EU-level.”

This editor analysed the report in copious detail and came to one inescapable conclusion: No matter how much one secures hardware such as cockpit doors, it is the software (the demons inside the human mind) that are the greatest single determinant of safety & security. Which is why the Task Force report devotes a much higher percentage of space focussing not on the cockpit doors, but on wider issues such as aeromedical checks, psychological evaluations of pilots, the aeromedical examiner framework, aeromedical data systems, the pilots’ work environment, stress factors and the role of drugs and alcohol. It also recognises the legal complications of privacy laws, and strives to reach a balance between medical secrecy and safety, so as “not to create additional red-tape for airlines.”

In broad brush-strokes, the Task Force recommendations are:

  • The principle of ‘two persons in the cockpit at all time’ should be maintained.
  • Pilots should undergo a psychological evaluation before entering airline service.
  • Airlines should run a random drugs and alcohol programme.
  • Robust programme for oversight of aeromedical examiners should be established.
  • A European aeromedical data repository should be created.
  • Pilot support systems should be implemented within airlines.

The first part of the report concentrated on two factors – hardware and external factors. Both relate to safety measures that were taken following the 11 September 2001 attacks to mitigate the risk of unwanted persons entering the cockpit. Secure cockpit door locking was rapidly mandated at international and European level. However, the report admits, “The focus for all the measures that were introduced was put on the threat from outside of the cockpit. A potential threat from inside the cockpit was not fully considered in either the initial phase or the period that followed, when the regulations were fine-tuned.”

It notes that use of the manual lock has been rarely required. Data provided by 10 European airlines and subsequent analysis carried out by European Aviation Safety Agency, showed that the rate is estimated at only 1 in every 250,000 flights. One specific case cited where the manual lock has proven useful, was in the US in 2012 when a pilot developed sudden psychiatric illness and was prevented from re-entering the cockpit through the use of the manual lock.

Immediately after the Germanwings disaster, EASA issued on 27 March 2015 a Safety Information Bulletin (SIB) temporarily recommending that airlines should ensure that at least two crew, including at least one qualified pilot, are in the cockpit at all times of the flight or implement other equivalent mitigating measures.

Having covered the hardware, the report then probes the software side. This is where things get a bit complicated. How does the aviation industry ensure that those flying the aircraft are of stable, balanced minds?

The report lays out a list of regulatory and procedural items that could be followed, including subjecting pilots to thorough aero-medical checks, psychological evaluations and more. But at every step, these recommendations prove to be both subjective, full of loopholes or otherwise unenforceable 100%.

The report admits at various stages, that not all medical events are predictable; that mental ill-health can also go undetected, or emerge at any time, even after the tests and training are completed. It notes that medical and psychological practitioners responsible for the certification can also have different evaluation standards and that licensing and certification procedures can differ from country to country. This raises questions about how often tests should be conducted, and where. Pilots, too, are under no obligation to report any problems, and often fail to do so for fear of losing their jobs. Other issues also emerge such as privacy: Who has access to that information?

One key part of the report deals with drugs and alcohol testing. It says, “The use/abuse of drugs and alcohol is one of the few disorders that has the potential to affect the mental health of pilots, for which screening by means of biochemical tests is available.

“Early recognition of drugs and alcohol problems is more likely in a company that has an active, clear, accessible and open reporting system, which promotes fair management of pilots with medical issues and has a good safety culture. Positive support and active rehabilitation is essential to encourage declaration of drugs and alcohol problems. The demonstration of a robust company stance differentiating between strong support for pilots who self-declare and intolerance of pilots who don’t declare and put their and others’ lives at risk is of paramount importance.”

The report notes that drugs and alcohol testing is legally mandated in a number of States and also undertaken by a number of airlines. It is currently being considered by more aviation authorities and airlines. The Task Force reviewed evidence from safety regulators and airlines undertaking drugs and alcohol testing, all employer-led rather than mandated by legislation. The Task Force also took account of legislation and practices related to drugs and alcohol testing in the road and rail areas.

It says, “Different scenarios were considered for the drugs and alcohol testing: pre-employment, with due cause (e.g. post incident/accident, whistleblowing report, on suspicion), periodic, random and follow-up (after tests). A number of elements to be considered for a drugs and alcohol testing programme were identified and analysed, including policy, training of staff, testing principles and implementation, quality assurance and issues for employers.

“Based on the analysis carried out, 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: in conjunction with the initial Class 1 medical assessment or when employed by an airline, post incident, post-accident, with due cause, as part of follow-up and after a positive test result. All operators’ Safety Management System should include a drugs and alcohol policy and organisations should be required to report the results of testing to the competent authority.”

Another key aspect deals with “Social Responsibility and Pilot Work Environment,” which is code for stress-factors. The report says, “Pilots, like other professionals, are susceptible to the effects of stress or negative personal situations and may sometimes be hesitant to seek help and support for a number of reasons. The obvious stressors include the work environment, psychosocial hazards such as fatigue and workplace or private problems, time pressure and stress sources all adults must deal with. This combination of factors may lead to temporary mental health issues or, if not recognised and treated, possible permanent issues.”

It adds, “The aviation sector is heavily driven by operational safety because of the regulatory and enforcement framework through European and national authorities. Obligations in relation to occupational health and safety, however, may not always receive sufficient emphasis from all stakeholders. The Task Force considered ways in which the employer can provide pilot support systems to facilitate the detection and early treatment of mental health issues, and the possible challenges that may be associated with such an approach.”

This report should be mandatory reading for Human Resources Departments or in any public or private sector enterprise. Stress, alcohol and drugs are omnipresent factors impacting on workplace productivity, decision-making and achievements of goals. They are ubiquitous in the travel & tourism industry. The Germanwings disaster proves that they can result in deaths just like terrorism and/or aircraft mechanical/structural problems. This was no pilot error or engine failure. It was mental failure.

Click here to download the EASA report.