The background

The EASA SIB 2015-04 was issued on 27 March 2015 as a direct response to the tragic GermanWings crash.

The crash, which took place on 24 March, was deliberate – caused by the co-pilot who waited for the captain to leave the flight deck and then locked the cockpit door and took control, flying the aircraft into terrain. He had previously been treated for mental health problems and was declared ‘unfit to fly’ but failed to report this to his employer.

What the SIB said

This Safety Information Bulletin (SIB) was issued almost immediately by EASA, and in fact near on all authorities put out something similar, saying there must always be two crew in the flight deck – if a pilot needs to leave for physiological reasons, a cabin crew member must be inside.

This was to ensure, should something similar be attempted, the additional crew member could try to over power the pilot and ensure the door could be opened to the other pilot still.

But, there was another reason best put by the recommendations in the SIC itself:

The Agency recommends operators to re-assess the safety and security risks associated with flight crew members leaving the flight crew compartment due to operational or physiological needs during non-critical phases of flight.

Based on this assessment, operators are recommended to implement procedures requiring at least two persons authorised in accordance with CAT.GEN.MPA.135 to be in the flight crew compartment at all times, or other equivalent mitigating measures to address risks identified by the operator’s revised assessment.

Any additional risks stemming from the introduction of such procedures or measures should be assessed and mitigated

This SIB was a recommendation put in place immediately following the accident to give authorities and operators time to assess the risk, and to find permanent mitigations to it. It was not a final ruling based on the investigation.

A quick note on the FD door

The flight deck door is heavily reinforced. In fact, following (a very long review process) 9/11, the FAA has mandated new FD door designs which have an additional ‘barrier’. That’s another story. Anyway, current doors are reinforced and have very robust systems and procedures in place to prevent FD interference (people entering who shouldn’t).

In order to enter, you need a code. When this is entered, the pilots visually identify the person trying to gain access and can check the surrounding area is clear. If they have any doubt they can deny entrance. If ‘LOCK’ is selected (or DENY on Boeing) then the keypad outside is disabled for a time period preventing further attempts.

If the pilots are incapacitated, there is a procedure to enable cabin crew to enter to provide medical assistance. I’m not going to share specific details of that here for obvious reasons, but will say that in the GermanWings accident, the captain attempted to enter the flight deck using this procedure and the co-pilot denied him access.

If you want more info, you can actually read all this in the Final Report.

What policies were put in place?

Following the release of the GermanWings investigation final report there were a whole bunch of safety recommendations by EASA, based on findings from the report. Many operators implemented more security procedures on top of these.

The main ones related to psychological evaluations for pilots, required during training and prior to them entering service at an airline. Random drug and alcohol testing was mandated, along with a robust oversight programme for AMEs (aeromedical doctors) to ensure when a medical licence is revoked, people know about it!

They also recommended things like pilot support and reporting systems (peer support and systems within the safety management system) to better protect and support crew suffering from mental health issues. Another recommendation (and only a recommendation) was that the 2 persons in the cockpit recommendation be maintained for a year so they could properly measure up the benefits/additional risks of it.

What happened after a year?

They reviewed the 2 persons in the cockpit policy. There was a lot of concern from pilot (and operators) that having a cabin crew inside actually raised new security and safety risks. There were also questions about whether they could really do much given the majority of pilots are male, and many cabin crew are female and smaller and less strong. Plus, they have limited training on what to do in this event…

You can read the full report here, but as a quick summary, who asked in the SIB was effective and mitigated risks, 28% disagreed and 54% strongly disagreed. A high percentage reported it raised more risks than it mitigated.

Based on this, they withdrew the SIB and SIB 2016-09 came into force instead. This recommends a performance based approach requiring operators to assess various things from their in-house support program and ability to mitigate psychological and social risks, to how the training needs and safety risks for them in having or not having an additional crew member in the flight deck.

Why bring it all up now?

Well, because recently there was an ‘incident’ in which a first officer became incapacitated while the captain was outside of the flight deck and a lot of people are in uproar that the airline didn’t have this procedure in place anymore.

The incident involved Lufthansa LH1140 from Frankfurt to Seville, and occurred just prior to TOD. It was on an A321. The preliminary report is here, but is in Spanish and I can’t find the Language option to change it so here is a mini summary in case you have the same problem:

• Prior to leaving the flight deck, the two crew discussed weather and operations, and the Captain did not notice anything unusual about the first officer’s behaviour
• The autopilot and auto thrust systems remained engaged, and the aircraft maintained its flightpath while the pilot was incapacitated
• The captain was outside the flight deck for around 10 minutes
• The captain attempted access using the emergency code, the co-pilot actually regained consciousness and opened the door
• They diverted to the nearest airport

Was any procedure broken?

No. And here are some further discussion points on that:

• Many operators no longer mandate a second person in the flight deck during toilet breaks
• Having to wait for a cabin crew to be available to come in is disruptive for the pilots and operational procedures, and for cabin crew trying to manage the cabin
• Many operators do specify a maximum time period to leave – usually around 5-10 minutes (adequate for a leg stretch and to have to queue for a toilet because passengers never let you in first)
• We often take controlled rest in the flight deck. This is usually around 30-45 minutes, during which one pilot rests/sleeps (is in an ‘unaware state”), while the other pilot maintains control and radio on their own (I am not saying anything would happen, just pointing out we have periods where we are not monitoring each other)

While safety margins were reduced, the flight did remain safe. This is also an extremely one of situation. To bring back in a policy that was considered “not fit for purpose” as a knee jerk reaction is unnecessary.

Are current policies good enough?

I don’t think so, but not in the way you might expect. First up, no, I don’t think we need a second person to enter the flight deck while we head out for toilet breaks. I think limiting it to 10 minutes and ensuring proper handovers with the remaining pilot is perfectly adequate. However, I do think a whole lot more on understanding and awareness of mental well-being is needed!

What I think we need:

• Better systems in companies for peer support and mental health support
• More practical, everyday understanding of how we operate on a ‘gradient’ of wellbeing, not a black and white ‘fit/not fit’ line
• Training for flight deck and cabin crew (all operational staff) on mental health and in particularly, recognising issues in colleagues
• Crew who are qualified in mental health first aid (available on every flight)
• Understanding and awareness about ourselves and how our performance is impacted
• Open discussions on how the things we try and leave outside the flight deck never actually stay outside!
• Develop a way to say “I’m not 100%” or to be able to ask the person next to us if they are (and know how to respond)
• Get over the idea it is embarrassing or “over sharing” to talk about these things

This might sound over the top, but consider this – when a pilot goes on a flight they check the aircraft is fit to fly via the tech log, using MELs to assess what is safe or not safe to go with, all in collaboration with ‘aircraft doctors’ (engineers!). They don’t hide it from the other pilot when they spot something on the aircraft that isn’t functioning right (so why are we about ourselves?) They check the weather to ensure the route and airports are suitable, they check they are compliant with FTls, they check airports are ‘fit for purpose’ through the NOTAMs…

The only thing we are not checking with a proper, fully considered procedure is whether we and our colleagues are ok! And this is arguably the most important thing because as the humans running this whole process, it’s sort of important.

The DUAL PASS OFF idea

This is a checklist, or maybe a memory item? A contingency review? for ourselves. We review our mental state to the other pilot, with our ‘crew partner’ and we sign each other off as ok. Hence the ‘dual pass’. If we aren’t 11/11 then we come up with mitigations, just like we do for operational issues in flight.

It covers what I reckon are the 11 core mental wellbeing issues which I personally find impact me in flight, and which I wish I could raise with someone, talk about, without being embarrassed. And I am not suggesting we have to go into detail with the other person, but just make them aware something is not ok for us, so what can we do as a crew about it?

D – Distraction

U – Uncertainty (confusion, startle)

A – Anxiety

L – Lack of Confidence

P – Pressure

A – Anger

S – Stress

S – Sadness (could include feelings of isolation)

O – Overload

F – Fatigue

F – Fear