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Learning From Disaster – Germanwings Flight 9525

airbus-a320-germanwings-d-aipx-crashedAs someone who has a lengthy professional background, as well as a personal interest and curiosity, in aviation – I, like millions of others who are watching the continuous coverage of the Germanwings disaster on every major news outlet, have a professional and natural human interest in this horrifying situation that took place Tuesday 24 March 2015.

But, as is the case in most, if not all, disastrous incidents there are valuable lessons to be learned.

I feel it is important that we highlight and discuss these lessons so as to arm ourselves against repeating past mistakes, or to close gaps that may not have been as apparent before. Not doing so, in my opinion, would be an added disaster of incredible magnitude, knowing we had the knowledge and experience to prevent such a recurrence.

Can we predict the future?

It’s human nature that we are not gifted with the ability to see the future – regardless of the claims some might make to the contrary – and that we cannot foresee all events or deficiencies that may lead to an eventual unfavorable situation, but in many cases we have the ability to assess situations and with proper attention and analysis we can make educated assumptions and mitigate risks to prevent undesirable outcomes from occurring in the first place.

Whether you are connected to the aviation industry or not – I’m certain you will be able to relate to the concepts I discuss in this article – I felt it important to highlight some of the issues that are believed to have been factors in the untimely death of 150 souls on board this ill-fated flight. By doing so we can bring these lessons forward in our own careers and improve the processes that we encounter on a routine bases.

How can quality management help us?

For most people, when they think of quality management, have the misconception that it only applies to technical functions such as reducing defects in manufacturing or quality control inspections after we perform a technical activity, but the more I hear of the factors leading up to the Germanwings crash, it reinforces and compels me to share my view that quality management philosophy, process, and procedure are not only important, but vital in every part of an organization, and all professionals should be encouraged to incorporate its philosophies and concepts, whether it be technical, corporate, regulatory, or social.

It will not only show in your contribution to your organization but will have a positive effect on your career as well.

Evaluating the gaps

So what does this little “ra-ra” quality rant have to do with the Germanwings crash you may ask? Well lets take a look at the main factors believed to have been the cause of flight 9525 crashing into the French Alps on Tuesday. Taking into consideration that it is still early and there is much more investigation to be done before confirmation of the facts, but it is fairly certain that the flight was intentionally brought down by the co-pilot once the Captain left the cockpit.

This raises the obvious question as to what would provoke a trained pilot to intentionally maneuver a commercial jet into terrain, killing himself and the passengers whose safety was his primary responsibility.

Contributing Factor #1: Medical disclosure

Well one would assume, and this is becoming more and more apparent as additional details come to light, that there was some sort of mental unbalance or illness at play here. In fact, it was discovered during a search of the co-pilots residence, that he had in fact been issued a medical note from the doctor stating that he was “Unfit to work”.

In addition to this discovery, it is being reported that he may also have been treated for depression in the recent past yet none of this information was reported to the airline, or to his superiors, as it is deemed the responsibility of the individual to be forthcoming and report any and all medical, mental, or social issues that may have an effect on their ability to fly.

Now, it may be that I possess a superior ability, through my years of quality management experience and training, to spot the possible “chink in the armor” with this process, or, the more likely explanation, is that there is a glaring deficiency in this otherwise efficient system.

I am an optimist at heart and I realize most pilots recognize the responsibility they hold, respect that responsibility, and are willing to do the right thing in these situations to divulge any issues that may affect their ability to perform their jobs safely and effectively, but the implications of such full disclosure could find them shut out from doing the very thing they love and are trained to do – flying airplanes.

Not to mention the financial impact that this could have should they suddenly find themselves out of a job that they have spent thousands of hours and dollars to obtain. They have families and responsibilities to consider as we all do.

Contributing Factor #2: Cockpit door lock system

The second contributing factor in this tragedy was the ability of the co-pilot to effectively lock out the Captain once he left the cockpit to use the restroom. Leaving himself in complete control of the aircraft in order to carry out this unspeakable deed, while the Captain was left helpless with the rest of the passengers on the other side of a reinforced door.

The security system installed on all transport category aircraft carrying passengers implemented after 9/11 provides an automatic locking system on the flightdeck door with a secret code allowing flight crew (Captain and Co-pilot) access should they find themselves locked on the cabin side of the door. This system also provides the ability for the flight crew to “Deny” or override this code function from a control panel located in the cockpit, leaving the door in the secured and locked position.

Although this is a simple yet effective system in performing the function and it was designed for – which is keeping people with malicious intentions out of the cockpit – the situation in the case of Flight 9525 was not an obvious consideration to its designers and policy makers.

Contributing Factor #3: Minimum 2 crew in cockpit at all times

The third factor which also relates to cockpit access, is the requirement, or lack of such requirement, of having a second person in the cockpit at all times and never leaving a single individual alone in control of the aircraft.

This has many advantages, such as providing assistance should the remaining pilot become incapacitated unexpectedly due to a sudden medical issue, or to provide assistance of any kind until the other pilot was able to return. The European Aviation Safety Agency (EASA) has already issued a temporary recommendation that this action be implemented by all airlines.

What can we learn?

Now, I think it obvious in hindsight, that by mitigating any one of these factors discussed above would have given the crew a chance to change the fate of this flight and its passengers and crew, or even prevent the opportunity for this to happen in the first place.

If the psychological issues and treatment would have been brought to the attention of the airline beforehand, and not left to the discretion of the individual who, as we have discussed, had a lot to lose in making such a disclosure and was suffering from a mental disorder and not to be relied on to make such a decision for himself.

If the cockpit door locking system had some failsafe worked into it to prevent a single individual to barricade himself, leaving the captain helpless on the other side of the door, or having a policy or process in place that ensures that the flightdeck is occupied by two crew members at all times.

In order to help us to make such policy and procedure, we must have the tools to analyze and interpret situations both technical and operational to develop sound processes before negative or costly consequences can arise. Now there is no guarantee, or method available to foresee every scenario, or gap before it happens, but it is clear to me that there is no area of business, service, or regulation where the concepts of quality management and process development are not useful and beneficial.

The concepts and philosophies of quality management can provide individuals with new ways of looking at their own positions and the contributions they can ultimately offer and not just leave it up to the “quality departments” or policy makers.

The fate of Flight 9525 is truly a tragedy and an unspeakable heartbreak for the families of the 150 passengers and crew, and almost an unbelievable event for those of us following the details unfolding in the news, but it is vital that we learn from the lessons provided to us.

What do you think? Leave a comment and share your views on this topic.

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This Post Has One Comment
  1. If only I could write like you. I would share similar views. I am not a writer. I’m a reader who likes your unique article.

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