Accident reports in aviation analyse the causes of accidents and usually indicate suggestions for improvements for prevention of similar events in the future. Procedures are criminalistic and use criminological methods, however, only for the sake of causal research, not to assign guilt: that is the responsibility of justice, notwithstanding the fact that there may be a substantial difference between responsibility and guilt, especially in exceptional professions like that of airplane pilots. Judiciary in Germany has remained rather silent during this past year, prosecutors referring to the final report of the french BEA[1] [2] as the source of detailed information regarding causes. Accordingly, a report free of errors or omission of facts is indeed of importance. However, there are several errors in this BEA-report, and contradictions, mainly regarding medical certificates as a precondition for the pilot’s licence:
Example 1:
P.17: “From July 2009, he obtained each year a class 1 medical certificate valid for one year that was endorsed with the note ‘‘Note the special conditions/restrictions of the waiver FRA 091/09 -REV-’’.
P.17: “On 28 July 2009, he obtained a new class 1 medical certificate valid until 9 April 2010, ….’’. Thus, the certificate was NOT issued for one year, but for 8.5 months. Furthermore, it is not explained anywhere, why, despite this certificate until April of 2010, he received yet another revalidation:
P.31: “Revalidation of class 1 medical certificate …..” on February 24, 2010, and yet another “Renewal of class 1 medical certificate…. ” on June 18, which is just another 4 months later. Similarly, on March 29, 2011, another renewal:
P.32: “Renewal of class 1 medical certificate …..”, and so in November 2011. Thereafter, for the first time, renewal followed after one year, in November 2012. Following this singular annual interval, renewal was again issued after 9 months, in August 2013.
P.17: “The last valid class 1 medical certificate had been issued on 28 July 2014 and was valid until 14 August 2015”. Thus, 8 months without flightmedical exams had passed at the time of the accident.
These irregular intervals are indicative of abnormal events regarding the copilot’s health. Since his license carried an entry regarding his mental health, it is likely that these events questioned his fitness to fly; otherwise, no interventions would have been required in these shorter intervals, instead of the usual annual intervals.
These irregularities taken together with the information of 41 consultations of doctors in the respective interval, questions arise that warrant detailed analysis of procedures regarding medical exams in view of ICAO[3]-rules for pilots with psychiatric disease and suicidal tendency. Thus the BEA would have been required to investigate, whether, and inhowfar, these certificates at irregular intervals were due to further signs of psychiatric disease or medication. Such detailed analysis and critique of german administration is missing, however, would have been of crucial importance, because recurrent signs of the disease had warranted immediate suspension of the copilot’s license. Accordingly, the BEA failed to elucidate some of the most important informations for later judicial assignment of responsibilities.
Example 2:
The BEA report mentions two informations from a psychotherapist which, each in itself, should have caused suspension of the copilot’s license in 2010 at the latest, if not already in 2009, according to ICAO rules:
P.31: The “Psychiatrist working for the Lufthansa AeMC” received report by treating psychiatrist and made phone call with treating psychotherapist in July 2009 “recommending providing class 1 medical certificate”. It is unclear, who made this recommendation and decision, respectively; which is important, because only an aviation medical doctor is supposed to be sufficiently familiar with ICAO-rules. One is therefore left behind with the assumption that the “Psychiatrist working for the Lufthansa AeMC” decided all on his own, without reporting to the LBA, which is against ICAO-rules, however, according to German law. Furthermore, a letter by the psychotherapist from August 2009 is reported to have contained “recurrent depressive disorder”, an information which he reportedly withdrew later – the respective explanation in the BEA-report remains unclear, which is alarming especially in the light of the fact, that the copilot was still in psychotherapy at that time, and for another 6 months, while being described as fully recovered.
Since an unstable psychiatric patient (a stable person does not require psychotherapy) may not be called fit to fly, not to speak of a pilot’s license, according to ICAO-rules, the lack of critique by the BEA warrants critique in itself; both informations, the indication of recurrent symptoms, revoked during continued psychotherapy, as well as its continuation during activity as a pilot, lack the required attention from the perspective of flight safety, as well as of legal consequences.
Example 3:
P.32: “All the AMEs from the Lufthansa AeMC who examined the co-pilot for the revalidations of the class 1 medical certificate were aware of the waiver that the co-pilot had. They all assessed his psychological and psychiatrist fitness through observation of behaviour and discussions.” According to ICAO-rules and recommendations, close controls at short intervals by a psychiatric specialist are required following psychiatric illness of such duration (9 months, thereafter continuation of psychotherapy, together well over one year). By no means do “observation of behavior and discussions” certify that the patient had indeed been checked by a specialist aware of ICAO’s restrictive rules. An error in the BEA’s analysis, which is even more important in view of the fact, that the BEA itself indicates that the copilot had “suicidal ideation, made several “no suicide pacts” with his treating psychiatrist and was hospitalized.”(P.30). The BEA’s critique, if any, is very discrete at this point, when it is mentioned that:
P.57: “In France no AME has ever issued any medical certificate to a pilot who has declared using anti-depressant medication.”
Example 4:
The copilot was required to obtain a separate medical certificate for a pilot license in the USA. Reportedly, documents were submitted upon request, and a license issued thereafter. However, the report does not mention that the psychiatric expertise submitted to the FAA was already a year old. The American licensing authority FAA also ignored the fact that the copilot had not answered their request for specialist proof of actual psychic stability and state of medication, and issued the pilot’s license. The BEA does not indicate this mistake made by the FAA, the omission of which could have prevented this pilot in training from ever getting hold of a license again.
Summary:
A patient is issued a pilot’s license one year after allegedly suffering from purely reactive depression without signs of psychosis or other (a diagnosis which has finally proven wrong), however, repeatedly having to make “no suicide pacts” with his psychotherapist because of his suicidal tendency. He is declared fit to fly and should undergo the usual annual medical examinations thereafter, with no requirements for closer medical observation. Although completely cured, he requires psychotherapy for another half year, while flying. His medical certificate, to be issued for 12 months, is issued for only 9 months with no accompanying explanation, however, is re-issued already after 7 months, again after another 4 months, and again at irregular intervals with only one exception, all without indication of reasons, except one suspicion of recurrent depression which would have warranted suspension of the license, not its renewal. This trace of irregularities can be followed down to the day of the catastrophe.
These unclarities, if not inconsistencies, regarding medical checks and issues of medical certificates are documented in this final report by BEA, however, remain without critical comment and emphasis. These deficiencies in the report explain frustration and disappointment both among relatives of the victims and members of the aviation community.
[1] BEA – Bureau d’Enquêtes et d’Analyses pour la Sécurité de l’Aviation civile,
equivalent to BFU in Germany (Bundesstelle fürFlugunfalluntersuchung).
[2] https://www.bea.aero/no_cache/en/investigation-reports/accessing-reports/
[3] ICAO – International Civil Aviation Administration
airborne 