Germanwings ja EASA - Trafi.fi - Etusivu European repository containing medico-administrative information, limited to Class 1 medicals, would deliver a significant benefit and be more

Germanwings case and the EASA Task Force

Matti Sorsa 2015

Germanwings 9525 24 March 2015

Matti Sorsa Pilot Select Oy 2015 2


Since 1980 6 Accidents. - 423 Fatalities.

29 November 2013 – LAM Flight 470 – Embraer ERJ-190 – 33 Fatalities 31 October 1999 – Egypt Air Flight 990 – Boeing 767 – 217 Fatalities 11 October 1999 – Air Botswana – ATR 42 – 1 Fatality 19 December 1997 – Silk Air Flight 185 – Boeing 737 – 104 Fatalities (Unconfirmed) 21 August 1994 – Royal Air Maroc Flight 630 – ATR 42 – 44 Fatalities (Unconfirmed) 9 February 1982 – Japan Airlines - DC8 – 24 Fatalities:


EASA • Transport Commissioner, Ms Violeta Bulc tasked EASA to create a task

force following the accident of Germanwings flight 4U9525 on 24 March 2015.

Objective • The aim of the task force is to prepare high-level recommendations in

the fields of pilot medical monitoring, operational mitigation measures, and other related subjects considered relevant by the task force, aiming at the prevention of future accident and incidents.


Task Force Members Alain Bassil, COO, Air France

Patrick Cipriani, Director for Civil Aviation Safety, DGAC France

Filip Cornelis, Head of Unit – Aviation Safety, European Commission DG MOVE

Dr. Sally Evans, Chief Medical Officer, UK CAA Andrew Haines, Chief Executive, UK CAA

Pekka Henttu, Director General, Finnish Transport Safety Agency (TRAFI)

Marc Houalla, President, École Nationale de l’Aviation Civile (ENAC)

Kay Kratky, COO, Lufthansa Patrick Ky, Executive Director, EASA

Prof. Dr. Helmut Landgraf, Aeromedical Center Vivantes Klinikum

Paul Reuter, Technical Director, European Cockpit Association

Matti Sorsa, Chief Psychologist, Pilot Select Oy Geoff Want, Director Safety and Security, Easyjet

Dr. Elizabeth Wilkinson, Head of Health Services, British Airways Matti Sorsa Pilot Select Oy 2015 6

1. The application of the 2-persons-in-the-cockpit rule

2. The assessment of pilots

3. AME qualifications and training, recurrent examination, and process oversight:

4. The electronic cockpit door lock system

5.Creating an EU repository for medical data

6.Creating a socially responsible culture/environment for pilots

TASKS


Recommendation 1:

• The Task Force recommends that the 2-persons-in-the-cockpit recommendation is maintained. Its benefits should be evaluated after one year. Operators should introduce appropriate supplemental measures including training for crew to ensure any associated risks are mitigated.


2. Psychological evaluations for initial pilot selections – the basis (MS) • Evaluation of applicants for airline pilot training

(self-sponsored vs. state/airline sponsored) is essential. Airline entry selection is also necessary (except perhaps in the case of MPL)

• Both of the above shall be done using shall be done with aviation psychological expertise assured by the training organisation and airline respectively


Aeromedical (MS)

• Aeromedical examination plays a less role in this risk management

• It is unreasonable – and unfair - to assume that an AME should evaluate the pilot’s mental condition during a short meeting

• In case any doubt exists from any source the AME should be able to use psychological/psychiatric expertise for consultations and possible referrals


Initial C1 Medical Assessment • General mental health assessment ‘appearance/ speech/ mood/

thinking/ perception/ cognition/ insight/ signs of alcohol or drug misuse’

• Heavily reliant on history given by applicant

• May lead to referral for psychiatric or psychological review

• No ‘screening’ tests for psychiatric disorders exist (reporting of symptoms = disorder present)


Recurrent Aeromedical Assessments • Aeromedical assessment and advice in between medicals is essential component • Guidance material needed in Part MED eg. on the acceptable level of incapacitation risk • Fit and proper person: concerning/criminal behavior

Note • increasing tests likely to adversely affect flight safety by taking time that should be directed to clinical assessment. • trusting relationship with AME is key


European Society of Aerospace Medicine (ESAM) • More rules wont solve the ‘GW’ problem. • A change in culture is required. Across the spectrum. • AME should not work in isolation, needs good relationship with AMS and ideally other AMEs • Computerized records essential. It is the 21st century. Pilot tourism is a reality. Central database of ‘unfit’ or special conditions.


ESAM

Confidentiality IS NOT THE SAME as secrecy. • ‘Bolt on’ psychological/psychiatric questionnaires likely to be an impediment. • Detection of dishonesty is difficult, especially at ‘fit and proper’ level. • Research is needed to improve the tools of psychosocial assessment. Note ‘psychosocial’ • AME training. QA of initial. Adequacy of refresher…20hrs/3 years.


Recurrent psychological assessments and safeguards • No recurrent psychological test system is feasible

(time factor, reliability) • Recurrent psychological testing is not necessary –

operational surveillance is continuous and covers both training and line work. Simulator checks reveal performance variations and raise questions of psychological/neurological problems.


Recommendation 2:

• The Task Force recommends that all airline pilots should undergo psychological evaluation as part of training or before entering service. The airline shall verify that a satisfactory evaluation has been carried out.

• The psychological part of the initial and recurrent aeromedical assessment and the related training for aero-medical examiners should be strengthened. EASA will prepare guidance material for this purpose.


Recommendation 3:

• 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:

- initial Class 1 medical assessment or when employed by an airline, - post-incident/accident, - with due cause, and - as part of follow-up after a positive test result.


Recommendation 4:

• The Task Force recommends the establishment of robust oversight programme over the performance of aero-medical examiners including the practical application of their knowledge.

• In addition, national authorities should strengthen the psychological and communication aspects of aero-medical examiners training and practice.

• Networks of aero-medical examiners should be created to foster peer support.


4. Cockpit door lock – no recommendation - ICAO Annex 6 requires a “secure” cockpit door - ORO (ORGANISATION REQUIREMENTS FOR AIR OPERATIONS) .SEC.100 - Flight crew compartment security: Lockable door required if more than 60 pax. or 45.5t - ORO.SEC.100 (c)(2) Monitor the area in front of the cockpit door from either pilot station. - FAR 129.28 Flight deck security applicable to foreign operators. - CS 25.795 requires a secure flight deck door if required by operating rules.


5. Creating an EU repository for medical data • Data protection vs Safety: the legal landscape • How it is ensured in EASA rules • Implementation in by Member States • Specific issue of medical data: collection, retention, sharing • Links to other EU and/or national rules


The Task Force reviewed the feasibility of a European aeromedical data repository containing basic medico-administrative information and of a comprehensive aeromedical records management system to supersede national systems. The practicality of implementing a full pan-European aeromedical records management system at this time was questioned. - cost, - lengthy implementation time, - data security and - difficult buy-in from stakeholders.


A European repository containing medico-administrative information, limited to Class 1 medicals, would deliver a significant benefit and be more readily accepted by aero-medical examiners and other stakeholders. - basic personal information (name, date of birth), - State of License Issue (or to which the pilot has applied for a

medical certificate if yet to achieve a licence) and - details of the aero-medical examiner who issued the last

medical certificate and current fit status. (While acknowledging the limitations of the repository, it could as an act as interim measure to a future full aeromedical records system.)


Recommendation 5:

• The Task Force recommends that national regulations ensure that an appropriate balance is found between patient confidentiality and the protection of public safety.

• The Task Force recommends the creation of a European aeromedical data repository as a first step to facilitate the sharing of aeromedical information and tackle the issue of pilot non-declaration. EASA will lead the project to deliver the necessary software tool.


6. The operational work environment • Pilot operates within a team, not only in the cockpit, but during

courses, simulators... No airline pilot works alone (vs. many other safety-related professions)

• Highly proceduralized work with checklists, call outs where deviation from the norm may be easily noted.

• Regular checking and training throughout the year • LOFT, Line Checks, interactive “class room” CRM may help to detect

issues early on • Last resort, reporting systems (confidential or not) in case of unresolved perceived safety issues during a flight.


What we need to avoid: • Undue additional burden on the pilot by introducing additional

stressors like regular psychological testing • Jeopardizing the mutual trust that crew needs among themselves and

towards their organization to be able to take safety relevant decisions. • Creating an atmosphere of anxiety and paranoia where any personal

trait or behavior will be looked at and scrutinized. • Taking measures that drive pilots with mental issues underground due

to fear for their livelihood • Throwing Just Culture principles out of the window


Potential risks

• If some sort of routine psychological/psychiatric evaluation were included in the recurrent medical examination there is a real danger of false findings that end people’s careers unnecessarily and create massive legal problems

• If operators do not promote openness and do not offer proper channels for psycho-social support there is a risk that pilots cover their normal life problems


Legal issues and authorities

• If authorities are ready to redraw licenses even when pilot has a natural life problem (such as divorce) which causes a temporary life crisis there is a risk that pilots do everything to conceal their problems

• If information about pilot’s mental state problems does not reach operators and authority for national legal reasons the safety net fails


Proposals for improvement (1)

• The initial selection (to ATP training and to an airline) is the key factor in the risk management – this shall be done professionally and using stringent criteria

• During pilot’s career continuous monitoring of pilot’s behaviour and performance variations by the employer and colleagues is essential



• All operators shall ensure that their safety culture is open and fair so that pilots can trust the employer and reveal their training, operational and life problems without fear of losing their jobs and they should have access to psycho-social support when needed

• All these aspects should be required to be included in the operator approved SMS



• In case information about pilot’s problems is available (to an AME, other medical doctors, pilot’s colleagues, his superiors etc.) national legislation should be examined to see whether for legal reasons this information does not reach the employer or the authorities early enough to enable corrective actions


Recommendation 6:

• The Task Force recommends the implementation of pilot support and reporting systems, linked to the employer Safety Management System within the framework of a non-punitive work environment and without compromising Just Culture principles. Requirements should be adapted to different organisation sizes and maturity levels, and provide provisions that take into account the range of work arrangements and contract types.


Finally (MS)

• The Germanwings case was an extremely rare a case and does not justify new and drastic measures.

• The aviation industry risk management system when applied as described above covers all reasonable risks


Finally (MS)

• The most important element is the initial selection that is done properly. After that the normal airline training and operational practices cover the risk sufficiently if employers are assuming their responsibility and can offer professional treatment channels to pilots

• The authorities should require this to be included in their approved SMS.

• Operators (Airlines) should promote a fair and open culture where pilots can discuss their problems such as training issues, family problems etc. without fear of losing their jobs and they should have access to psycho-social support when needed


Way Forward • Task Force proposes that EASA is tasked with the production of an

action plan for the implementation of the recommendations stemming from this report. This should include a prioritisation of actions considering cost and time factors.


Action Plan (7Oct2015)

• Global Aircrew Medical Fitness workshop 2015 loppuun mennessä • Lukuisia kv-organisaatioita (IATA, IFALPA; EFT; IACA, ESAM etc.) • Concept paper for consultations Operational Directives 2016 alussa => implementations (NAA’s), AMC+GM’s

Follow-up in standardisation meetings (inc. The use of of the European aeromedical repository)


Germanwings ja EASA - Trafi.fi - Etusivu European repository containing medico-administrative information, limited to Class 1 medicals, would deliver a significant benefit and be more

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