Following-up on the statements issued by the French Prosecutor as reported in the press , I wonder if the French Prosecutor has been too hasty in jumping to a conclusion? Here is how I look at the situation as is reported in the press.
The prosecutor says, I quote, “At this moment, in light of investigation, the interpretation we can give at this time is that the co-pilot through voluntary abstention refused to open the door of the cockpit to the commander, and activated the button that commands the loss of altitude … It appeared that the intention of the co-pilot, identified as Andreas Lubitz, had been "to destroy the aircraft." He said the voice recorder showed that the co-pilot had been breathing until before the moment of impact, suggesting that he was conscious and deliberate in bringing the plane down … The captain is heard pleading to get back into the cockpit, but the co-pilot, heard breathing normally until the plane crashes, does not react … You can hear the commanding pilot ask for access to the cockpit several times. He identifies himself, but the co-pilot does not provide any answer … You can hear human breathing in the cockpit up until the moment of impact … the breathing did not indicate any health problem such as a heart attack.”
Firstly, the fact that the co-pilot is heard breathing is in itself an anomaly. In most cockpit recordings, it is not possible to figure out the breathing at all due to ambient noise inside the cockpit of an aircraft. The fact the breathing is heard at all, is an indication that this breathing could not have been normal, but had to be “labored and heavy” to be audible over the other noise. Please visit these links to listen to some actual CVR recordings so you can understand how much of noise is recorded and how heavily someone would have had to breathe to be audible above this kind of noise.
The prosecutor says, I quote, “At this moment, in light of investigation, the interpretation we can give at this time is that the co-pilot through voluntary abstention refused to open the door of the cockpit to the commander, and activated the button that commands the loss of altitude … It appeared that the intention of the co-pilot, identified as Andreas Lubitz, had been "to destroy the aircraft." He said the voice recorder showed that the co-pilot had been breathing until before the moment of impact, suggesting that he was conscious and deliberate in bringing the plane down … The captain is heard pleading to get back into the cockpit, but the co-pilot, heard breathing normally until the plane crashes, does not react … You can hear the commanding pilot ask for access to the cockpit several times. He identifies himself, but the co-pilot does not provide any answer … You can hear human breathing in the cockpit up until the moment of impact … the breathing did not indicate any health problem such as a heart attack.”
Firstly, the fact that the co-pilot is heard breathing is in itself an anomaly. In most cockpit recordings, it is not possible to figure out the breathing at all due to ambient noise inside the cockpit of an aircraft. The fact the breathing is heard at all, is an indication that this breathing could not have been normal, but had to be “labored and heavy” to be audible over the other noise. Please visit these links to listen to some actual CVR recordings so you can understand how much of noise is recorded and how heavily someone would have had to breathe to be audible above this kind of noise.
If any breathing could be heard over this kind of background noise, the first conclusion that I reach is that the Co-Pilot was not in normal condition of health to be breathing so heavily as to be audible on the CVR tape. The second is that if he was intentionally about to crash into a hill, there would certainly be a change in his breathing pattern…and this has not been reported. My assessment here is that Co-pilot was certainly not in normal state of health and was in all probability incapacitated.
Secondly, the cockpit door can be opened from outside by entering an Emergency Code. When an emergency code is entered, an audible noise sounds inside the cockpit and then, unless a latch is engaged by the pilots inside, the door would open after a short time delay. While the French prosecutor makes reference to noise of breathing, that in any case would have been difficult to hear, and makes further reference to Captains attempts to breakdown the door, there is no reference to any audible sounds related to his attempts to open the door from outside. So the questions that arise here are, did the Captain never attempt to open the door using his Emergency Code? If not, why not? If yes, why the associated sounds are not heard and mentioned in the Prosecutors report? Further, if the Captain did try to open the door using his emergency code, is there any evidence of the Co-Pilot blocking this attempt?
At the end, the only conclusion I can reach is that the French Prosecutor seems to have been in too much of a hurry to put the blame on the Co-pilot. There is no hard evidence to support this hypothesis. It is certainly a possibility, but at this time there is no hard evidence to label an innocent man a criminal guilty of a ghastly crime involving murder of about 150 passengers and crew members. More professional analysis and interpretation of the available data is necessary before any conclusions can be reached.
Going further, I firmly believe that because all human performance occurs inside an Organizations Policies and Procedures, any human error can always be traced to Organizational deficiencies. We have had at least three incidents of such nature before and two of those I had mentioned in my book “Into Oblivion”. The first point that comes to mind here is that in all the previous cases, the termination of flight when intentional was immediate, by the pilot pushing the aircraft into a steep dive and crashing into ground within 2 to 3 minutes. So, why here the aircraft took eight minutes to impact? This comparatively long delay certainly needs some explanation.
However, following these, FAA issued a regulation requiring a crewmember to enter and be present inside the cockpit whenever one of the Pilots leaves the cockpit for any reason whatsoever. However this regulation was not copied by EASA and hence was not mandatory to be implemented in Europe until today. Today, EASA has issued a ruling that mandates this, but until now this had not been done. The EASA AD issued today 27 March 2015 is located here: http://ad.easa.europa.eu/ad/2015-04. Further I wonder what were the policies and procedures at Germanwings as regards this Emergency Code to open the door. Was this followed on every flight? Did the Captain not know this code/procedure? Was it normal on Germanwings flights for the code to be ignored or the procedure not be included in recurrent training of the crew?
As you can see, the diagram I published earlier in my book "Waiting...To Happen!" is proved correct once again…Poor Organizational Policies and procedures set in motion two chains of accident events. First leads to poor workplace conditions and creates an accident through defeating the individuals into errors and violations. The second leads through lack of adequate risk management/controls to poor defenses in terms of Technology, Training and Regulation and become causative to accidents.
Once again, the Regulatory lapses at EASA and Organizational lapses at #Germanwings have succeeded in defeating individual human performances and I the Erring Human got an opportunity to strike once again...this time killing 150!
Stay Safe,
The Erring Human.
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