of them; Failures come as unpleasant surprises. They are unexpected and do not belong in the system.
Failures are introduced to the system only through the inherent unreliability of people.
This persistence into the notion that “Bad Apples” do exist and they are sharing negative attitudes
toward consistent behavior or that their problem is a personal or motivational one, an issue of mere
individual choice, forces people think that by throwing out the Bad Apples, all problems will be solved.
They are the same people that do believe that by adding more technology in our lives they are helping
human error to be removed. Unfortunately, they cannot see that their “perfect solution” does not
remove the potential for mistakes. It just relocates it or changing its nature.
The Germanwings Final Accident Report
A few days ago, nearly one-year after the
devastatin g accident that claimed the lives of 150
passengers on board a Germanwings Flight
destined from Barcelona to Düsseldorf, BEA (The
French Authority for Air Accident Investigation)
had published the Final Accident Report.
According to this report Causes to the accident
were the following: “The Collision with the ground
was due to the deliberate and planned action of
the co-pilot who decided to commit suicide while
alone in the cockpit. The process for medical
certification of pilots, in particular self-reporting in
case of decrease in medical fitness between two
periodic medical evaluations, did not succeed in
preventing the co-pilot, who was experiencing
mental disorder with psychotic symptoms, from exercising the privilege of his license.”
Complimentary to the causes of the accident the report referred to other factors that may have
contributed to the failure:
“The co-pilot’s probable fear of losing his ability to fly as a professional pilot if he had reported his
decrease in medical fitness to an AME; (Specialized doctor who is eligible to decide for the medical
fitness for pilots) The potential financial consequences generated by the lack of specific insurance
covering the risks of loss of income in case of unfitness to fly; The lack of clear guidelines in German
regulations on when a threat to public safety outweighs the requirements of medical confidentiality.”
Lastly some ink had been consumed to attribute the effective cockpit door design to security
requirements that had managed to resist forcible intrusion by unauthorized persons so far, but at least
in two occasions it failed to stop an accident from happening, I am referring to both the Germanwings
and secondly to HELIOS accident, as in the latter sight in the cockpit area had been deprived, which
had led pilots enter “hypoxia state” first and left as impossible the opportunity for anyone being able to
tackle “piloting” earlier.
Within the conclusions area of the report had been stated that:
“the co-pilot did not contact any AME;” (probably it refers that the co-pilot did not voluntarily had
revealed to an AME that he was taking medication prescriptions for anti-depression mitigation that
would had led to losing his flight license. “the mental state of the co-pilot did not generate any
reported concern from the pilots flew with him;” “no health care providers reported any aeromedical
concerns to authorities.”
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