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Airbus A320 crashed in Southern France

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Airbus A320 crashed in Southern France

Old 14th Mar 2016, 20:33
  #3421 (permalink)  
 
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Here is the final report:

https://www.bea.aero/uploads/tx_elyd...0125.en-LR.pdf
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Old 14th Mar 2016, 20:59
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I have searched the final report several times.

Apparently the Captain or flight attendants never inputted the emergency access code - why?

How is it possible to change the selected altitude from 38,000 to 100' in one second?

Does German Wings altitude setting SOP make use the 1000' or 100' selection on the FCU?

Would it not take 4-5 twists of the altitude selector to go from 38000 to 100' even if the 1000' selection was used because one would have to switch to the 100' mode to input 100' in selected altitude?
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Old 15th Mar 2016, 05:40
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Apparently the Captain or flight attendants never inputted the emergency access code - why?
I can't see where the report states that. Reference?

How is it possible to change the selected altitude from 38,000 to 100' in one second?
I'm obviously missing something subtle.. from what I've seen when jumpseating on a 'bus I'd have thought you'd probably do it the same way you do on a Boeing MCP, i.e. turn the knob quickly...

Last edited by wiggy; 15th Mar 2016 at 06:59.
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Old 15th Mar 2016, 12:51
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page 9

"He kept the cockpit door locked during the descent, despite requests
for access made via the keypad and the cabin interphone."

I read that as they entered the Emergency code but he jsut switched it to LOCK every time thus overriding the keyboard
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Old 15th Mar 2016, 13:37
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Page 36:

"Note: The buzzer recorded at 09 h 34 min 31 most probably corresponded to a routine access request because it is the first access request following the Captain's departure from the cockpit and because the operator's normal practice calls for trying the normal access code before dialling the emergency access code. Therefore, the possibility that it corresponds to an emergency access request cancelled after 980 ms by an action on the toggle switch is considered to be extremely remote."

From what I read all requests for access were via the routine (normal) method. The emergency access method was never attempted. If it were there would be additional sounds recorded emanating from the door specific loud speaker. Also considering the time frame he would have needed to select lock only once and all subsequent requests for access (routine or emergency) would have been muted.

I fly the Bus, I can spin the selected altitude knob and maybe go from 38,000 to 22,000 then have to spin again and most likely one more time to get to 1000 and then reset it to the 100' range to get to 100' feet. So 3-5 spins - I don't think I could do that in a second - is it a big deal ofcourse not - it just stood out to me.
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Old 15th Mar 2016, 13:50
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I did see that comment but as I read that it seems to only refer to that particular singular (and seemingly first) request for access. Even in that comment they say can't even definitively rule out that it wasn't an attempt at emergency access, just that it was extremely unlikely because of SOPs. That in turn might perhaps lead to the conclusion that the investigators had no way from the audio data of ever telling which "code" was used for entry.

Maybe it's more clear in the original French langage version.

(Edit to add:spent too long typing - I appreciate you maybe can't answer but is the buzzer sound for normal access the same as the buzzer for emergency access?)

As for the comments about the " Alt knob" on the MCP Thanks for your comments, I wonder if the "one second" is plus or minus. I'm not planning to try it but you could certainly wind most Boeing MCP alt selectors down to 100' in not much more than a second.
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Old 15th Mar 2016, 14:05
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RAT 5:
When do the supposed/perceived rights of the individual over-ride the established rights of the many? Does not a doctor, as well as having a 'duty of care' to his patient, also have 'duty of care' to society in general. The medical oath is to save life. Do the laws of privacy over-ride one's scariness about a patient's future actions?
I can speak to the duties of a psychiatrist in the United States. First and foremost, psychiatrist are afforded more protection by law than other medical doctors or than other types of mental health practitioners.

Psychiatrists cannot disclose fantasies that a patient may have. Nor can the psychiatrist disclose past crimes the patient may have confessed. But, if the patient makes a credible threat to commit a crime then the psychiatrist is required by law to report that specific threat to law enforcement.
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Old 15th Mar 2016, 15:17
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But, if the patient makes a credible threat to commit a crime then the psychiatrist is required by law to report that specific threat to law enforcement.
And that part is not different in Germany. However, it has to be very credible, otherwise the psychiatrist will be open to litigation.
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Old 15th Mar 2016, 15:53
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I know this is a professional pilot forum but bear with me. Just before Christmas 2014 a truck crashed into a crown of Christmas shoppers in Glasgow, Scotland killing 6 and injuring 15. Turned out the driver was suffering blackouts and despite being on medication did not till his employers for fear of loosing his job.
This is a global multi-industry problem it impacts aircrew, train drivers, coach drivers, passenger ship crew and probably a lot of people in other industries.
1 in 4 people will suffer a mental health issue at some stage (not all suicidal) and because the problem is global, it affects all cultures and nationalities, its no good one country bringing in regulations if nobody else follows suite.
So you have to design a system that will not stop the majority of people who now seek help, keeping quiet for fear of their jobs, and it being acceptable to all cultures and nationalities.

We need to change the perception of mental health issues, to employers, employees, governments and regulatory authorities on a global scale.

That is a very very big task, and persoally I cannot see it happening any time soon.

Hope I am wrong and somebody wiser than me comes up with a workable solution quickly.
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Old 15th Mar 2016, 16:54
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When the emergency access code is entered the cockpit buzzer sounds continuously for a period of time (company specific but probably 10-30 seconds) in the cockpit. During this period of time the door remains locked. The cockpit occupant can select deny on the cockpit door switch thus denying entry. If deny is selected, the door remains locked. Any further inputs on the cockpit access panel are ignored and the buzzer inhibited for a period of time (company specific but probably 10-20 minutes) If nothing is selected the cockpit door will unlatch for a very short period of time allowing entry.
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Old 15th Mar 2016, 17:08
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Originally Posted by Mainsail
I know this is a professional pilot forum but bear with me. Just before Christmas 2014 a truck crashed into a crown of Christmas shoppers in Glasgow, Scotland killing 6 and injuring 15. Turned out the driver was suffering blackouts and despite being on medication did not till his employers for fear of loosing his job.
This is a global multi-industry problem it impacts aircrew, train drivers, coach drivers, passenger ship crew and probably a lot of people in other industries.
The only way round this I can see is some kind of loss of license insurance. It would have to be mandatory, and built into employment contracts. People with financial commitments are just not going to admit health problems that will end their career without an adequate and mandatory safety net.
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Old 15th Mar 2016, 17:32
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Even that only addresses the financial aspects. Without a cultural acceptance, there's still the "X couldn't hack it, he must be weak" etc stigma. How many people who suffer "burnout" and admit it, feel trusted again, or ARE trusted again? "We can't give Y this challenging task, you know what can happen (wink, wink)" It's not even necessarily malicious, the person saying that likely thinks they are somehow "protecting" the person.

Money is of course important, but not by any means the whole story.
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Old 15th Mar 2016, 19:14
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In the UK the General Medical Council places a requirement on doctors to over ride individual patient confidentiality if the risk to society or others is greater. The obvious one is an absolute requirement to report a stabbing, even though some are not the result of crime.

The issues are

a some countries have privacy laws and dont have a GMC

b doctors are busy and dont always know exactly what a patient does

The flip side of all this is that pilots might not seek help for either physical or mental health issues, exacerbating as opposed to solving the problem.
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Old 15th Mar 2016, 22:07
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In essence the mental health aspect of the responsibilities of the healthcare professionals is obvious. If Lubitz had said he had plans to crash his aircraft into a mountain then yes the professional had to do something about it.

I dont think in actuality it would have been that clear, even with hindsight. The normal questions asked tend to follow a formula. Are you feeling suicidal? That is a yes or no question. This is followed if the positive is given, Do you have any plans? If its a no then whatever the suspicions of the medics then they are not on firm ground to do much.
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Old 16th Mar 2016, 21:37
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One thing I just thought about was that a big problem could be the number of doctors Lubitz went to.

This way he spread out the crazy to several doctors, enough that noone could see just how much crazy he had. Although some of them did acknowledge the crazy and wrote him prescriptions and sick leave, they were not entirely in the loop. It was only after-the-fact when all doctor notes had been collected that the total crazy became evident.

Is there any airline that has an appointed psychiatrist for crew members? This, including job security, could reduce risks much more than putting a CC member in the jumpseat. IMHO of course. And SLF status behind the keyboard, I might add.
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Old 16th Mar 2016, 21:48
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Actually, ignoring for now the issue of whether someone poses a risk to others.

IF a docyor considers you are suicidal, then you pose a risk to YOURSELF and I would imagine that gives them a duty to you - their patient - to do something about it. The fact that none of the doctors involved sought anything more as an action than a referral or a sick note or whatever suggests that none saw anything that escpecially worried them.

I don't think they need any kind of "duty to inform an airline" - the pilot's a threat to himself anyway, and is that not enough?

With the full acknowledgement that i don't know what any particular law might say regarding doctors and potentially suicidal patients.
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Old 17th Mar 2016, 00:09
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In 2000 Dr Harold Shipman was found guilty in the UK of killing 15 patients. And an Inquiry suggested that he may have killed over 200.

The UK medical standards and training were altered to prevent a repeat, with modern data processing. Patients have been able to allow this information to be used to improve the Health Service.

Whether this had been possible to allow such information to the Central Medical Board in the case of Civil Pilots, I know not. (The CMB has recently had its long experience in such matters, much reduced, which may be a pity.)

Something along the lines of the U.K's Medical Records arrangements might have made the many Medical consultations by Lubitz worth noticing, especially as they may have been with different Doctors.

Modern Information technology would not have been available when the Confidentiality requirements were (understandably) imposed, but that was,now, several decades ago.

LT

Last edited by Linktrained; 17th Mar 2016 at 00:48. Reason: spelng etc
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Old 18th Mar 2016, 00:43
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As pilot I was required to have a Medical every six months and one of these every two years had to be at C.M.B. Doctors told me of one pilot who had passed his Medical in the morning - and then dropped dead in the street in afternoon. ( The unpredictable - as has been mentioned by others.)

"Six monthly flying checks" do not appear to have been done, until I had completed some 3500 hours with two different U.K. employers and different aircraft types, mainly Trooping worldwide, as the only other pilot, on board ( just a C.P.L. with I/R were enough, even to operate some B.O.A.C. First Class services.) Standards as well as passenger capacities and speeds have altered since !

LT
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Old 18th Mar 2016, 07:29
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IF a doctor considers you are suicidal, then you pose a risk to YOURSELF and I would imagine that gives them a duty to you - their patient - to do something about it.
It's a bit more complicated than that. If a patient is clearly barking, then they can be sectioned. However, if they say, 'Doctor, I'm 92. All my friends have died. My knees keep me awake at night. I'm not depressed, but I think I've had enough.' and they don't have signs of clinical depression then you would try to help them medically or practically, but almost certainly couldn't section them, and you couldn't break medical confidentiality to their relatives either.

The truth of the matter is that a lot of people are at some risk of killing themselves, but only a small proportion of these will benefit from being coerced onto a psychiatric ward.
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Old 18th Mar 2016, 16:36
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Here is a very well reasoned article from Flight Global pointing out the difficulties faced by those who are suffering from depression or from some other mental health problems:-
https://www.flightglobal.com/news/ar...mental-423276/
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