June 21, 2020
[Ed. Previously published August 4, 2019.]
This will be a a discussion about the factors that allowed Andreas Lubitz, young Germanwings co-pilot, to crash an airliner into the French Alps at 700 miles per hour, killing himself and 149 others, without anyone who knew of his mental instability preventing him from continuing on active flight status. These are some of the reasons why it could happen in Germany why its is much less likely to happen in the Unite4d States.
After 17 years of practice as a Family Physician, I worked for the decade of the 1980’s as an Occupational and Environmental physician, heading up the SFO regional medical department of a major airline.
Following World War I, when it had been discovered that about as many pilots were lost to accidents caused by their own ill health as were shot down by the enemy, the military established the position of Flight Surgeon, and gave medical officers with that designation the power to determine pilot fitness for duty, and even the power to overrule the orders of line commanders regarding flight status. By the 1980’s, several airlines had full-service medical departments dealing with employment health and injuries. Their Flight Surgeons worked closely with the FAA’s Aeromedical Certification Branch in Oklahoma City, and had primary lines of responsibility to flight safety, the employees and the airline itself.
When I was an airline’s regional flight surgeon at SFO, which included our maintenance base, we served 25,000 local employees, of which a couple of thousand were pilots.
Not every airline had a medical department, and the jobs of my staff of 20 were constantly in jeopardy during the decade of the ‘80s, when hostile takeovers were rampant and “deregulation” had struck the aviation industry, resulting in dozens of little start-up airlines with no debt or pension load. The start-ups undercut prices severely, and the established airlines struggled to cut costs in order to compete.
Management debated year after year regarding whether to shut down the company medical department and rely upon outside contractors to provide “occupational medicine” support.
As one of the first in the company to be issued an IBM personal computer in about 1983, a departure from the corporate practice of doing everything on a huge mainframe, my hobby interest in computing had led me to write a very large relational database program on my PC that tracked demographic, medical and disability data resulting from the more than 2,000 visits per months to our medical department. Before it was over I had collected data on more than 100,000 consecutive visits to the medical department. As a result, my monthly reports were able to show that while it cost about a million dollars a year to fund my regional medical department, if the company had outsourced only the federally mandated exams, less than half our workload, to outside occupational medical clinics, it would have cost twice our department’s annual budget.
Our regional facility did pre-employment exams, with drug testing, on all employees except pilots, who were hired and drug tested by a special team at the airline’s training center in Denver. We saw all work injuries and did “fitness for duty” or return-to-work determinations on all employees, including pilots. In my experience over the years, outside doctors rarely if ever had the slightest idea what the various jobs of our employees entailed. They didn’t know, for instance, that pilots were forbidden from taking any of dozens of common medications, including any sedatives, depressants, anti-depressants, anti-seizure medications, anti-histamines, etc, etc, etc. Which is why any flight crew return-to-duty order by an outside doctor had to be rechecked by my staff of two other flight surgeons, two nurse practitioners and myself.
The FAA requires an annual or six-month physical for pilots. It is cursory, but covers certain critical things, like eye exams and an EKG. In addition to those exams, we also did a very comprehensive annual physical on our pilots,
which covered every aspect of life and health. Always including an inquiry into alcohol consumption and medications and a question about street drugs and nicotine use.
The general rule in aviation is that no pilot may resume flying if suffering from any condition which could cause “sudden or insidious incapacitation” in the cockpit.
It should be understood that the best defense against cryptic illness or drug use was the integrity of the pilot himself or herself, who was obligated by law to report any significant change in health. It was, and is still the case that any significant adverse change in health, reported or not, automatically voids the pilot’s official federal medical certificate, and with it his or her license to fly.
In the hiring process each pilot was administered a full battery of psychological tests, administered by psychologists, and was interviewed by our full-time company MD-psychiatrist.
The company also had a very active Employee Assistance Program (EAP), and participated as a founding member, along with the Airline Pilot’s Association (ALPA) and the FAA, of the Human Intervention and Motivation Study (HIMS).
Our EAP, medical, and union reps all participated in week- long annual trainings in intervention, evaluation and monitoring of pilots with alcohol or related substance abuse, dependency or mental health problems.
We did group interventions, with employer union and family members present, upon pilots who were brought to our attention by family or fellow pilots, or who showed abnormalities in, for instance, liver function tests.
After a 28-day inpatient program and a couple of months of successful and whole-hearted participation in a 12-step program, it was my responsibility to decide whether it was safe to return the pilot to the cockpit. Upon my recommendation to the FAA chief psychiatrist in Washington, the pilot’s license was restored and he returned to work while being monitored by my group for an additional few months. Following which he or she was questioned extensively during the annual physical.
The HIMS program was the first of its kind and was the pattern for ones now used for physicians, and people in other jobs where public safety is key. The recovery rate for pilots during the 80’s was 96%. This past year some addiction specialists have questioned whether my assertion of that recovery rate is credible. There are few records or reports still available on-line, but those that remain confirm that it was in that range, and that number is my personal recollection regarding a program in which I was deeply involved.
Pilots who were not detected before committing a firing offense, like showing up in the cockpit drunk, were fired, then invited to use their full medical benefits to undergo several months of treatment and AA follow-up.
Not all airlines participated in the HIMS program. Some maintained, “We don’t have any alcoholic pilots”. Yeah. Right.
During the years I worked for the airline, three other airlines closed their medical departments and relied solely upon the exams done by FAA Aviation Medical Examiners, (AME’s), private physicians designated by the FAA to do physical exams on pilots.
My impression is that at this point in the US very few airlines have their own medical department, though they may have a “medical director’ and contract with clinic groups who by now have become as knowledgeable about FAA requirements and flight safety as we were at my airline.
On the other hand, perhaps because of the extensive spying that was done upon citizens in East Germany and the egregious misuse of private information thus obtained, at the time of the crash of Germanwings Flight 9525m Germant had very strict laws regarding the privacy of mental health issues. The laws were so strict that they prevented the flow of information from several mental health professionals aware of Lubitz’ suicidal nature, from ever reaching management decision-makers at Germanwings.
In the U.S. we have a similar problem regarding the reporting of dangerous mental conditions to those who maintain the National Instant Criminal Background System (NICS), in order to prevent certain mentally ill people from obtaining firearms. According to my most recent look at the numbers, only about 46 states require reporting. Of those, many do not forward the reports from the responsible state agency to the FBI for inclusion in the NICS database. While states require hospitals and institutions to report, and may include mandatory reporting for judicial determinations of mental illness or incompetence, there is rarely a requirement for treating physicians or clinicians to report mental illness, in the way that reporting is required for obvious reasons of public safety for venereal disease or infectious diseases like measles.
In the U.S., when there is a full airline medical department, the employer has an in-house expert who can evaluate outside medical information and pass real-time judgment on fitness for duty. Privacy insulation comes from the fact that the in-house medical team passes only a disability status recommendation to management, and not any specific medical information. At the same time management is able to be absolutely sure that company physician recommendations will conform to flight safety requirements, and that an airline doctor understands precisely what they are and what is at stake. That confidence also descends from the federal government. At my airline we were actually also designated as Senior AME’s by the FAA, as FAA Medical Sponsors in the HIMS program and as drug test Medical Review Officers (MRO) for the Department of Transportation, so we had a strong line of responsibility to the federal government and public safety, as well as one to the company.
The Germanwings crash triggered a debate regarding the withholding of information by mental health practitioners from the company medical staff. And Even such information as was communicated to company medical officers was not given to managers in charge of pilot assignments. Even then, medical and aviation officials argues against relaxing the confidentiality rules. A year after the crash, investigators recommended allowing physicians to report known dangers to authorities. Years afterward the problem has been addressed in some countries and remains unresolved in others.