The investigation team, under the
lead of French BEA, has published a preliminary report on the accident to
#Germanwings flight 9525 and the full report can be access here: http://www.bea.aero/docspa/2015/d-px150324.en/pdf/d-px150324.en.pdf
While the report does not tell us
too much more than what has already been made public in the press, it does
clarify some important technical doubts that have been voiced in various social
media as well as my earlier posts.
On the issue of “Human
Breathing”, the report states as follows, Quote “A sound of
breathing is recorded both on the co-pilot track and on that of the Captain
throughout the accident flight. This breathing, though present on both tracks,
corresponds to one person’s breathing. It can be heard several times while the
Captain was talking (he was not making any breathing sound then) and is no
longer heard when the co-pilot was eating (which requires moving the microphone
away or removing the headset). The sound of this breathing was therefore
attributed to the co-pilot.” Unquote.
It is very interesting to note
that even the Captains microphone recorded only the Co-pilots breathing, while
not recording Captains breathing or even that of the flight attendant who was
present in the cockpit for a short period of time. As I had mentioned in an
earlier post on this blog, if any sound of breathing is recorded in a CVR tape,
it cannot be normal breathing. This statement is now corroborated by the fact
that even the Captains mic, that was very close to his face, recorded only the
Co-pilots breathing and not of the Captain. We have evidence here that the
Co-pilot was certainly not breathing normally, and not just when the Captain
was absent from the cockpit! The co-pilot was clearly in distress on that
fateful day and it is surprising that this very audible sign was missed by all
around him. There is certainly a need here to probe deeper into this aspect of
evidence and if the crew underwent any nature of pre-flight medical evaluation
on that day or, if this heavy and abnormal breathing was also noticed by any of
the ground crew (eg. Flight Despatchers) who interacted with the Pilots prior
to departure and while on ground in Barcelona. It will also be significant here
to understand if there was any change in the rate, volume or frequency of this
breathing sound, especially at the time when Captain left the cockpit.
Another very significant detail
in this report is the revelation of what transpired during the onward flight to
Barcelona. The Captain apparently left the cockpit at 07:20 hrs. The aircraft
then received instructions to descend from its cruise altitude of 37,000 ft to
initially 35,000 ft and later to 25,000 ft. and the co-pilot descended the
aircraft according to these instructions, stabilizing correctly at 25,000 ft.
So far nothing is unusual. What is surprising here is the manner in which this
descent was carried out by the Co-pilot. Instead of making a selection to
35,000 ft and later changing that to 25,000 ft, he appears to have been
“playing around” with the auto-pilot controls. As the graph below depicts, he
made multiple, seemingly random changes, varying from the minimum possible
selection of 100 ft to the maximum possible selection of 49,000 ft! This behaviour
is highly unusual and needs some evaluation. The press is going viral calling
it a practice of what was to follow or even an aborted attempt to intentionally
crash the aircraft. However, to my mind, this might represent something very
significantly different. To me, this represents the behaviour of someone
experiencing psychomotor problems…essentially, a lack of coordination between
mind, eyes and hands! He seems to be hunting for the correct selection and
unable to reach one. It could also represent a casual attitude or lack of
seriousness, even indecisiveness. All of these could, in turn, be related to
the reported psychological distress caused either because of mental depression
or maybe, a more serious and undiagnosed state of Schizophrenia.
While the aircraft was correctly descended according to ATC instructions and stabilized at the requested level, the manner of achieving this was irregular and reflective of state of mind of the pilot. A deeper psychiatric evaluation is certainly necessary here and I hope BEA is investing sufficiently into such nature of professional evaluation.
A similar behaviour is also noted
in the minutes leading to the crash. The report states,
“At 9 h 33 min 12 (point 5), the speed management changed from “managed”
mode to “selected” mode. A second later, the selected target speed became 308
kt while the aeroplane’s speed was 273 kt. The aeroplane’s speed started to
increase along with the aeroplane’s descent rate, which subsequently varied
between 1,700 ft/min and 5,000 ft/min, then was on average about 3,500 ft/min.
At 9 h 33 min 35, the selected speed decreased to 288 kt. Then, over
the following 13 seconds, the value of this target speed changed six times
until it reached 302 kt.”
Once again, we see evidence of
“playing around” with speed selections…either unable to make a selection or
undecided on what selection to make, or maybe just playing with the selector
knob like a fidgety child.
Another significant aspect
highlighted in the report occurred just after the Captain left the cockpit. The
event is documented as follows:
- At 9 h 30 min 24 (point 3), noises of the opening then, three seconds later, the closing of the cockpit door were recorded. The Captain was then out of the cockpit.
- At 9 h 30 min 53 (point 4), the selected altitude on the FCU changed in one second from 38,000 ft to 100 ft. One second later, the autopilot changed to “OPEN DES” mode and autothrust changed to “THR IDLE” mode. The aeroplane started to descend and both engines’ rpm decreased.
- At 9 h 31 min 37, noises of a pilot’s seat movements were recorded.
- At 9 h 33 min 12 (point 5), the speed management changed from “managed” mode to “selected” mode. A second later, the selected target speed became 308 kt while the aeroplane’s speed was 273 kt. The aeroplane’s speed started to increase along with the aeroplane’s descent rate, which subsequently varied between 1,700 ft/min and 5,000 ft/min, then was on average about 3,500 ft/min.”
The Co-pilot was seated and
settled in his seat. He had been flying for some time. So, why at this point
should there be any need to move/adjust his seat? Did he at this point move
from his seat to the Captains seat? Did he have a reason to leave his seat? It
will be significant to note if there were any changes in his breathing pattern
at this stage because then there is another item in the report that causes
concern. The report documents, “low
amplitude inputs on the co-pilot’s sidestick were recorded between 9 h 39 min
33 and 9 h 40 min 07” and then again, “An
input on the right sidestick was recorded for about 30 seconds on the FDR 1 min
33 s before the impact, not enough to disengage the autopilot.” Both these
texts refer to the same event, although they appear in different sections of
the report.
Was this a last minute attempt by
a man struggling to regain control of his own body to recover and save the
situation?
Yet another significant aspect of
this report relates to the cockpit door access alarm. “At 9 h 34 min 31 (point 7), the buzzer to request access to the cockpit
was recorded for one second.” Further,
- the cockpit call signal from the cabin, known as the cabin call, from the cabin interphone, was recorded on four occasions between 9 h 35 min 04 and 9 h 39 min 27 for about three seconds;
- noises similar to a person knocking on the cockpit door were recorded on six occasions between 9 h 35 min 32 (point 9) and 9 h 39 min 02;
- muffled voices were heard several times between 9 h 37 min 11 and 9 h 40 min 48, and at 9 h 37 min 13 a muffled voice asks for the door to be opened;
- noises similar to violent blows on the cockpit door were recorded on five occasions between 9 h 39 min 30 and 9 h 40 min 28;
- low amplitude inputs on the co-pilot’s sidestick were recorded between 9 h 39 min 33 and 9 h 40 min 07;
In the description of the door
locking system fitted in the accident aircraft, it states that, “…To request access to the cockpit from the
passenger compartment, the normal one-digit access code followed by ‘‘#’’ must
be entered on the keypad. A one-second acoustic signal from the buzzer sounds
in the cockpit to warn the crew that someone wishes to enter…The flight crew
then moves the three-position switch:
- If they pull and maintain the switch in the UNLOCK position, the door unlocks. The acoustic signal stops. The green LED lights up continuously on the keypad to indicate the door has been unlocked. The door must then be pushed in order to open it. A magnet in the cockpit is used to keep the door in the open position.
- If the flight crew moves the switch to the LOCK position, the door is kept locked. The acoustic signal stops. The red LED lights up continuously on the keypad to indicate locking is voluntary. Any interaction with the keypad is then disabled for 5 minutes (until the extinction of the red LED). At any time, the crew in the cockpit may cancel this locking by placing the switch in the UNLOCK position. The door then immediately unlocks.
- In the absence of any input on the switch, the door remains locked. No LEDs light up on the keypad. The acoustic signal stops after one second.”
It is significant that after just
one access request at 09:34, no further request is recorded on the door lock.
It is reasonable to assume at this point that the selector switch inside the
cockpit was put in “Locked” position, thereby disabling the keypad for 5
minutes. However, did the Captain not know about this 5 minute interval? Why
did he not make yet another attempt 5 minutes later, at about 09:39 to use his
emergency access code?
As highlighted in my earlier blogposts
also, human error is not a disease. It is a symptom of the disease called “Poor
Organizational Management”. Several flaws in Germanwings and Lufthansa
management have been highlighted by this accident and it is those shortfalls in
management that created the setting in which the accident scenario could be
played out. Lufthansa has much to learn from this accident about management of
human resources and about preventing humans from erring. As for Germanwings, if
they thought safety was expensive, they have now had a taste of an accident.
The writing is already on the wall…investors have already decided to liquidate
the Germanwings brand and merge the assets with Europewings. This is not the
first time an airline has had to be liquidated because of an accident, and
unless the managements learn very quickly about managing humans like humans and
not objects, I fear that this will not be the last time also!
Stay Safe,
The Erring Human.
