Crash of Germanwings flight 95252 Leads to Questions

By ThinkReliability Staff

On March 24, 2015, Germanwings flight 9525 crashed into the French Alps, killing all 150 onboard. Evidence available thus far suggests the copilot deliberately locked the pilot out of the cockpit and intentionally crashed the plane. While evidence collection is ongoing, because of the magnitude of this catastrophe, solutions to prevent similar recurrences are already being discussed and, in some cases, implemented.

What is known about the crash can be captured in a Cause Map, or visual form of root cause analysis. Visually diagramming all the cause-and-effect relationships allows the potential for addressing all related causes, leading to a larger number of potential solutions. The analysis begins by capturing the impacted goals in the problem outline. In this case, the loss of 150 lives (everybody aboard the plane) is an impact to the safety goal and of primary concern in the investigation. Also impacted are the property goal due to the loss of the plane, and the recovery and investigation efforts (which are particularly difficult in this case due to the difficult-to-access location of the crash.)

Asking “Why” questions from the impacted goals develops cause-and-effect relationships. In this case, the deaths resulted from the crash of the plane into the mountains of the French Alps. So far, available information appears to support the theory that the copilot deliberately crashed the plane. Audio recordings of the pilot requesting re-entry into the cockpit, the normal breathing of the co-pilot, and the manual increase of speed of the descent while crash warnings sounded all suggest that the crash was deliberate. Questions have been raised about the co-pilot’s fitness for duty. Some have suggested increased psychological testing for pilots, but the agency Airlines for America says that the current system (at least in the US), is working: “All airlines can and do conduct fitness-for-duty testing on pilots if warranted. As evidenced by our safety record, the U.S. airline industry remains the largest and safest aviation system in the world as a result of the ongoing and strong collaboration among airlines, airline employees, manufacturers and government.”

Some think that technology is the answer. The flight voice recorder captured cockpit alarms indicating an impending crash. But these were simply ignored by the co-pilot. If flight guidance software was able to take over for an incapacitated pilot (or one who deliberately ignores these warnings, disasters like this one could be avoided. Former Department of Transportation Inspector General Mary Schiavo says, “This technology, I believe, would have saved the flight. Not only would it have saved this flight and the Germanwings passengers, it would also save lives in situations where it is not a suicidal, homicidal pilot. It has implications literally for safer flight across the industry.”

Others say cockpit procedures should be able to prevent an issue like this. According to aviation lawyers Brian Alexander & Justin Green, in a blog for CNN, “If Germanwings had implemented a procedure to require a second person in the cockpit at all times – a rule that many other airlines followed – he would not have been able to lock the pilot out.”

After 9/11, cockpit doors were reinforced to prevent any forced entry (according to the Federal Aviation Administration, they should be strong enough to withstand a grenade blast). The doors have 3 settings – unlock, normal, and lock. Under normal settings, the cockpit can be unlocked by crewmembers with a code after a delay. But under the lock setting (to be used, for example, to prevent hijackers who have obtained the crew code from entering the cockpit), no codes will allow access. (The lock setting has to be reset every 5 minutes.) Because of the possibility a rogue crewmember could lock out all other crewmembers, US airlines instituted the rule that there must always be two people in the cockpit. (Of course, if only a three-person crew is present, this can cause other issues, such as when a pilot became locked in the bathroom while the only other two flight crew members onboard were locked in the cockpit, nearly resulting in a terror alert. See our previous blog on this issue.)

James Hall, the former chairman of the National Transportation Safety Board, agrees. He says, “The flight deck is capable of accommodating three pilots and there shouldn’t ever be a situation where there is only one person in the cockpit.” In response, many airlines in Europe and Canada, including Germanwings’ parent company Lufthansa, have since instituted a rule requiring at least two people in the cockpit at all times.   Other changes to increase airline safety may be implemented after more details regarding the crash are discovered.