150 victims that could have been avoided: Andreas Lubitz, Lufthansa and the "human factor"




All security professionals who have dealt with crises - attacks, crime, treasons, serious workplace disasters – are familiar with a truth that was recently recalled by Lufthansa and its subsidiary Germanwings: in the overwhelming majority of cases, the problem is neither due to a technical failure, nor the quality of equipment or service, nor the compliance, or not, to procedures already in place. The problem is the human factor.


In other words, shielding the cockpit door of an A320 and develop an elaborate procedure for its opening / closing with the sake of preventing a hostile element from outside to take control of this crucial place is certainly an excellent thing. This procedure was introduced in the aftermath of the 9/11 attacks to avoid the use of aircrafts as bombs crushing into buildings. However, it is useless if the "system" is unable to prevent a psychologically "fragile" person (to use a euphemism) from sneaking through the cracks, and locking himself into the cockpit to use the same security measures to perpetrate his deadly work.


If the latest information from Germany are correct, what we have just described is what has exactly happened in the case of Lubitz. The drama, here, is that this lesson must be learned at a price that cost the lives of 150 people.


Let us recall some key events. In 2009, Andreas Lubitz, then aged 22, was training at the Lufhtansa flight school in Bremen, where it had to stop the training due to episodes of "panic attacks" and "deep depression". According to the German newspaper Bild Zeitung, the psychiatric episodes lasted a year and a half. Later, he had to repeat his training courses "several times" following new depressive episodes.


Later on, when he was attending the Airline Training Center Arizona in Phoenix, United States, his instructors categorized him as "not airworthy" and marked his profile with acronym “SIC”, which means he was supposed to attend regular and special medical checkups.


The facts were, apparently, reported to the German authority for air traffic control (Luftfahrbundesamt or LFB - Federal Aviation Office) by the Lufthansa’s Medical Center, and, still according to the German media, Lubitz’s license was still marked "SIC"…


A document of the European Aviation Safety Agency[1] dated December 15th, 2011, (which takes regulations and standards already existing for years) tells us that "A history, or the occurrence, of a functional psychotic disorder is disqualifying unless a cause can be unequivocally identified as one which is transient, has ceased and will not recur. "Similarly, a candidate with a history of "schizophrenia, schizotypal or delusional disorder should only be considered for a fit assessment if the licensing authority concludes that the original diagnosis was inappropriate or inaccurate […]."


Obviously, one should be a psychiatrist and have access to Lubitz’s medical records to assess whether the depression was a psychosis. However, the “deep” and “recurrent” character of his condition and the repeating "panic attacks" clearly should have had listed him as “not airworthy” as he was in Phoenix.


These facts could not be unknown to Lufthansa’s managerial board and German authorities since they were found by Bild Zeitung’s journalists in Luftfahrbundesamt’s folders.


Therefore, Lufthansa has deliberately chosen to ignore the recommendations of the American instructors in Phoenix and decided to hire a pilot with a meaningful risky profile and assign him to fly an A320 that carries about 200 passengers. And this decision was ratified, or in any case was never challenged by the same authority responsible for aviation security. One could even wonder if the choice to put him working in a subsidiary company, and not in Lufthansa itself, was a sort of "probationary period", which would obviously be extremely serious.


Thus, it is clear that if Andreas Lubitz represented a risk, those who have allowed him to progress in his career - the direction of Lufthansa and LFB officials – are an even higher risk; Lubitz, by definition, could not understand what risk he was representing to others, but those who "covered" could not ignore it.


But they chose to ignore the facts and bypassing the safety procedures they had put in place themselves, along with being responsible for their implementation and / or enforcement. On a secondary basis, Lufthansa CEO, Carsten Spohr lied on Thursday afternoon press conference when he said that medical confidentiality prevented him to know if Lubitz had a problematic psychological profile.


Besides the fact that Lufthansa and the German administration, through their irresponsible decisions, are now in the heart of a major confidence crisis that can only have huge criminal and financial implications, it is extremely important to establish as soon as possible whether in Germany, or Europe, there are other pilots with similar conditions to those of Andreas Lubitz.


And it is particularly important that the consequences of this unprecedented crisis are learned and the responsible people brought to justice. The restoration of confidence, essential for the functioning of the system, is absolutely required.


© ESISC 2015




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