Germanwings: The Investigation E-Book

Simon Hradecky

• Herausgeber: novum publishing
• Kategorie: Gesellschafts- und Liebesromane
• Sprache: Englisch

Seitenzahl: 505

Veröffentlichungsjahr: 2025

Beschreibung

"Failure is not an option" – a principle long established in space exploration. Simon Hradecky now applies this motto to the investigation of the 2015 Germanwings disaster, challenging the official account of events. In his gripping book, Hradecky explores how technical malfunctions and other possible causes were systematically excluded from the investigation. The story of the crash is retold from a new perspective that goes far beyond the usual explanations. Through his own technical tests and extensive research, he demonstrates why the true reasons behind the crash remain hidden to this day. A must-read for anyone who wants to understand the full story behind this tragedy.

Leseprobe

Simon Hradecky

Germanwings: The Investigation

Imprint

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All rights of distribution, also through movies, radio and television, photomechanical reproduction, sound carrier, electronic medium and reprinting in excerpts are reserved.

Cover images: BORIS HORVAT / AFP / picturedesk.com (C) 2017; Chema Gomez (C) 20142

Cover design, layout & typesetting: novum publishing

Images: Staatsanwaltschaft Düsseldorf, Staatsanwaltschaft Marseille

Any inconsistencies in the text are due to the fact that it was translated using computer-aided technology for a company-wide study.

Foreword

"Failure Is Not An Option"

said Gene Kranz (full name Eugene Francis Kranz), aerospace engineer and NASA mission manager, whose determination and leadership enabled Apollo 13 to successfully return the crew to Earth in good health despite the serious accident on board. He explained further in his book of the same name:

"An engineer can explain how a system should work (in theory) but an operator has to know what the engineer knows and then has to know how the systems tie together to get the mission accomplished. If the systems break down the operator must make rapid decisions on fixing or working around the problem to keep the mission moving."

These words, for all their validity for Apollo 13, also sound like a prophecy for many aviation accidents, not least the crashes of the Boeing 737 MAX in Indonesia and Ethiopia.

However, these words are also applicable to air accident investigations and should be taken to heart by air accident investigators.

Last but not least, I would like to quote Albert Einstein in this context:

"Condemnation before investigation is the highest form of ignorance."

In my many years as a journalist, I often developed the feeling that air accident investigations all too easily took the path of least resistance and blamed the crew, who died in the accident and could no longer defend themselves, for the accident even before all other possible causes, e.g. technical, had been ruled out. The interests of living people such as designers, maintenance technicians, manual authors, decision-makers in aviation authorities and airlines etc. all too often gain the upper hand.

That's why I always side with the crew until it is proven that the crew caused the accident or all other possible causes have been ruled out.

Aircraft accident investigations serve to prevent further similar accidents and to eliminate the causes of such accidents. Therefore, if an investigation takes the path of least resistance, it does not fulfill its purpose, which was signed by most national governments of the world in the international agreement within the framework of the ICAO (International Civil Aviation Organization), and thus cannot improve aviation safety.

In the crash of the Germanwings A320 in the French Alps on March 24, 2015, the French public prosecutor Brice Robin condemned the co-pilot of the A320 as a suicide and 149 times murderer 49 hours after the crash even before the investigation was properly started - which again reminds me of Einstein's quote. According to the 21,000 pages of files compiled by the investigation, there was no other way for the investigation to confirm this conviction, all indications in other directions, although clearly present in the file, were ignored and no investigations in these directions were documented. When I asked questions in this direction, it became clear that the investigating authorities were stonewalling and did not even respond to the questions.

So what else could I do but analyze all the investigation files myself and form my own opinion?

Since the French air accident investigation BEA, which did not conduct the investigation in this crash, did not provide any data and documents beyond the final report in order to be able to verify statements in the final report, I had to rely on the files submitted by the investigator, the Marseille public prosecutor's office or the Marseille investigating court.

When I began my background research in 2017, I could not have imagined that it would paint such a devastating picture of an investigation that would be characterized by countless investigative errors, interpretations that are diametrically opposed to the facts established by the investigation itself, false assertions and false foundations for the conclusions, resulting in untenable conclusions and much more. I also could not imagine that the BEA final report would contain such serious errors in the facts that it could no longer be classified as reliable and factually correct as a whole and that it would consequently no longer be possible to rely on any of its statements. In this investigation, the cart was indeed put before the horse 49 hours after the crash.

In 2024, even in the latest A320 Neo, I was able to prove that the possibility of an uncommanded descent still exists, so the cause of the 2015 crash has still not been rectified.

The damage caused to international aviation by this investigation is immeasurable. The true causes of this crash remain obscure and latent to this day. It is therefore still possible that families will mourn their family members for the same reasons that 150 families mourned their loved ones in 2015 and continue to do so today.

Chapter 1

The day of the crash

As I do every morning, I sat in my office around 9 a.m. on March 24, 2015, a Tuesday, and began to read and answer the many emails that had reached me overnight. In my e-mails, I expected to receive information about possible incidents in aviation, on the basis of which I would then initiate research to verify the information, shed light on the background and then write a corresponding report on "The Aviation Herald" (AVH). Later I would then check the websites of the civil aviation authorities and investigating authorities for news.

I had always been interested in commercial aircraft (airliners), had developed a mathematical model that allowed me to simulate flight behavior, engine behavior, aircraft controls and aircraft systems in real time, and had begun investigating commercial aircraft accidents and incidents about 13 years earlier to obtain data on aircraft behavior that I could use to validate my mathematical model. I already knew that the full flight simulators used by airlines for pilot training were no longer accurate enough outside of normal flight envelope. For example, when the Lauda Air Boeing 767 crashed in 1991, it became clear that the simulator was suggesting to pilots that thrust reverser extension on one engine during a climb was definitely controllable. However, this turned out to be wrong, because the simulator programming had not taken into account that the turbulence of the airflow caused by the reverse thrust would cause large parts of the wing to stall, causing the wing to lose lift and the aircraft to roll uncontrollably. During these 13 years, I had regularly reported such incidents to my friends and presented my findings. My friends thought that the reports were worth being seen by a wider readership, my best friend Urs Wildermuth started to really work on me from 2007 and finally convinced me to take the plunge. I founded AVH in April 2008, the website went online after programming on May 12, 2008 and exceeded all expectations within a very short time.

As always during my office/editorial day, a TV was on in the background, the sound was quiet but still audible. News channels were usually on, as I didn't want to miss any incidents and publish my own report as quickly as possible. This morning, however, one of the German state broadcasters was on in the background.

I had just noticed that the German Air Accident Investigation Bureau (BFU) had published its monthly bulletin for November 2014, and had discovered that the BFU had published important new details about a serious incident we had already reported on November 5, 2014, when my eyes fell on the TV set with a ticker tape running across its screen: "German plane missing". It was shortly after 11 a.m. local time (Central European Standard Time CET, 10:00Z).

I dropped everything. Which plane? I studied the radar data, watched pilot forums, then it became clear that a Germanwings A320 on a flight from Barcelona to Düsseldorf, flight 4U-9525, had started to descend and had disappeared from the radar over mountainous terrain in the south of France. This must have been the missing plane. In the meantime, the first indications had already arrived that the plane had crashed and had been located on the ground.

At 11:54L (10:54Z) I published our first report:

Crash: Germanwings A320 near Barcelonnette on Mar 24th 2015, lost height and impacted terrain

A Germanwings Airbus A320-200, registration D-AIPX performing flight 4U-9525 from Barcelona,SP (Spain) to Dusseldorf (Germany), was enroute at FL380 about 30nm southeast of Marseille (France) when the aircraft initiated a rapid descent. Contact with the aircraft was lost at about 6000 feet. French Police reported the aircraft was seen on the ground near Barcelonnette (France).

Radar data suggest the aircraft descended from FL380 through FL110 in 8 minutes (average rate of descent 3375 fpm).

The first confirmations arrived that helicopters had found the plane. In the meantime, many German radio stations had interrupted their programs and special broadcasts were made about the crash.

New reports arrived almost by the second on all channels, e-mail, forums, TV stations, radio, online media and official sources.

I had already extended our report to 12:09L (11:09Z):

Crash: Germanwings A320 near Barcelonnette on Mar 24th 2015, lost height and impacted terrain

A Germanwings Airbus A320-200, registration D-AIPX performing flight 4U-9525 from Barcelona,SP (Spain) to Dusseldorf (Germany) with 142 passengers and 6 crew, was enroute at FL380 about 30nm southeast of Marseille (France) when the aircraft initiated a rapid descent. Radar contact with the aircraft was lost at about 6800 feet at approx. 10:45L (09:45Z) about 12nm southwest of Barcelonnette (France).

French Police reported two helicopters spotted the remains of the aircraft on the ground near Barcelonnette (France).

The President of France reported, it does not appear there are any survivors.

Radar data suggest the aircraft had reached FL380 about 3 minutes prior to leaving FL380 and descended from FL380 through FL110 in 8 minutes (average rate of descent 3375 fpm). The aircraft appeared to have levelled off at FL068 for one minute while on a northeasterly heading of 26 degrees true, mountains rise up to 8600 feet about 1nm north of the last reported aircraft position.

I hate the phone. It always interrupts at the wrong moment, especially when you're working on highly concentrated research anyway, the devil is loose in the newsroom, and I'm trying to stay organized and prioritize incoming information for publication at top speed, verify as much as possible within such a "breaking news" situation, and complete the article. I hate the phone.

But it rang. There was no number on the display. I picked up the phone, a voice answered without introducing itself, no name. But I quickly understood that the call must have come directly from the Germanwings headquarters. The caller explained to me that the technical logbook (Techlog for short, in which all observations of technical faults and the steps taken to rectify them are recorded) of the crashed aircraft, which was supposed to be closed and no longer accessible to anyone, was still open to everyone within the company. The techlog had already been computerized, there was no longer a techlog on paper. This tech log contained an entry stating that the cockpit door keypad, which could be used to knock on the door from the cabin or to open the door in an emergency using a special emergency code, was recorded as defective and that the repair had been postponed until later in accordance with the Minimum Equipment List and the associated procedures.

The conversation was over and I was puzzled. What was that all about? What did this information mean? Why did I receive this information? From whom? But I didn't have time to think. Information continued to pour in from all sides and wanted to be processed and edited.

France's civil aviation authority DGAC declared that the plane had sent an emergency call (which later turned out to be false).

I found time to prepare a graphic of the radar track. Shortly before the lunch break, when I would go to my favorite pub opposite my office, our report read:

Crash: Germanwings A320 near Barcelonnette on Mar 24th 2015, lost height and impacted terrain

A Germanwings Airbus A320-200, registration D-AIPX performing flight 4U-9525 from Barcelona,SP (Spain) to Dusseldorf (Germany) with 142 passengers and 6 crew, was enroute at FL380 about 30nm southeast of Marseille (France) when the aircraft initiated a rapid descent. Radar contact with the aircraft was lost at about 6800 feet at approx. 10:45L (09:45Z) about 12nm southwest of Barcelonnette (France), 75nm northwest of Marseille.

French Police reported two helicopter spotted the remains of the aircraft on the ground between Prads-Haute-Bleone and Barcelonnette (France) at about 2700 meters elevation (8800 feet), about half way between the two cities there is a mountain ridge rising up to 8900 feet.

The President of France reported, it does not appear there are any survivors. The crash site is very difficult to reach.

France's DGAC reported the crew transmitted an emergency call just prior to the aircraft disappearing from radar near Bassinet.

Lufthansa, parent company of Germanwings, reported they do not yet know what happened to flight 4U-9525.

Radar data suggest the aircraft had reached FL380 about 3 minutes prior to leaving FL380 and descended from FL380 through FL110 in 8 minutes (average rate of descent 3375 fpm). The aircraft appeared to have levelled off at FL068 for one minute while on a northeasterly heading of 26 degrees true, mountains rise up to 8900 feet about 1nm north of the last reported aircraft position.

Radar Track (Graphics: AVH/Google Earth):

I left the newsroom and hurried into the pub. The innkeeper knew I was in a big hurry before I had even entered the pub, although he hadn't heard about the crash. He could almost see me running across the zebra crossing, an unusual sight. "I'm in a hurry," I pushed out as I dropped into the seat at my regular table. My thoughts revolved around the A320 as I wolfed down the menu - I've forgotten what I ate, I wonder if I was even consciously aware of it that day. Even before the final "crowning glory" of the lunch, a large brown (double espresso with cream and sugar), was served, I paid, downed the coffee and ran back to the office.

In the meantime, I had received a huge number of emails and messages. I sifted through the new information, but there was nothing really new.

The phone rang, but again the display didn't show the caller's number. I picked up the phone. I already knew the voice, I received a short message that the entry about the defective keypad on the cockpit door was now missing from the machine's tech log, but that all other entries were still accessible.

I decided to make a file note for myself after all, even though I still had absolutely no idea what it meant.

I asked the caller if he had taken photos of the screen with the techlog entry and then the unsuccessful access. The caller said yes, but refused to send me the photos, saying that he feared for his position and even his life because he could be identified via the access log to the techlog, the time stamps and the like. I didn't ask any more questions, I still didn't understand how important this information would be later on.

The flow of information slowed down considerably. The media began to focus on the passengers on the flight, and there was hardly any relevant information about the flight itself.

The French Ministry of Defense published the first pictures of the quickly established helicopter base from which aid workers were shuttled to the crash site.

By 15:07L (14:07Z), our report had evolved and now read:

Crash: Germanwings A320 near Barcelonnette on Mar 24th 2015, lost height and impacted terrain

A Germanwings Airbus A320-200, registration D-AIPX performing flight 4U-9525 from Barcelona,SP (Spain) to Dusseldorf (Germany) with 144 passengers and 6 crew, was enroute at FL380 about 30nm southeast of Marseille (France) when the aircraft initiated a rapid descent. Radar contact with the aircraft was lost at about 6800 feet at approx. 10:45L (09:45Z) about 12nm southwest of Barcelonnette (France), 75nm northwest of Marseille.

French Police reported two helicopter spotted the remains of the aircraft on the ground at about 2700 meters elevation (8800 feet) between Prads-Haute-Bleone and Barcelonnette (France), about half way between the two cities there is a mountain ridge rising up to 8900 feet.

The President of France reported, it does not appear there are any survivors. The crash site is very difficult to reach.

France's DGAC reported the crew transmitted an emergency call just prior to the aircraft disappearing from radar near Bassinet.

Germanwings and Lufthansa, parent company of Germanwings, confirmed flight 4U-9525 suffered an accident in the French Alps. There were 144 passengers and 6 crew on board. A hotline for family member was opened at Phone Number (Germany): 0800 11 33 55 77.

In a press conference about 4.5 hours after the aircraft disappeared from radar Germanwings reported 144 passengers, among them 2 babies, and 6 crew were on board. The aircraft reached its cruise level at 10:45L, one minute later the aircraft left cruise level and initiated a descent over 8 minutes. Radar contact was lost at 10:53L at about 6000 feet. The aircraft had been delivered by Airbus to Lufthansa in 1991 and had undergone all needed maintenance checks. The captain had 6000 flight hours of experience.

Radar data suggest the aircraft had reached FL380 about 3 minutes prior to leaving FL380 and descended from FL380 through FL110 in 8 minutes (average rate of descent 3375 fpm). The aircraft appeared to have levelled off at FL068 for one minute while on a northeasterly heading of 26 degrees true, mountains rise up to 8900 feet about 1nm north of the last reported aircraft position.

Helicopter Base for Search and Recovery Teams (Photo: French Ministry of Defense):

Radar Track (Graphics: AVH/Google Earth):

The phone rang again, again without displaying the caller's telephone number, the already familiar voice answered and now reported that the techlog was now completely blocked for any access, which should have happened hours earlier.

Once again, I tried to persuade the source to send the photos of the Techlog entries, referring to the constitutionally guaranteed protection of sources, our editorial secrecy, but to no avail. The source made it clear that he was too afraid of being discovered and the possible consequences. This call turned out to be the last contact with this source, the voice remained unidentifiable even for me, the contact broke off.

I was still puzzled and could not place this information. As I had no proof of the information that the cockpit keyboard was defective, I was unable to report this detail.

The first photos of the crash site were received. ATC rejected the Civil Aviation Authority's report that the aircraft had declared an emergency. I began to analyze the first photos to determine the position of the crash site.

The French Ministry of the Interior reported that a first black box (either a flight data recorder (FDR) or a cockpit voice recorder (CVR)) had been found and recovered.

At 18:34L (17:34Z) our report read:

Crash: Germanwings A320 near Barcelonnette on Mar 24th 2015, lost height and impacted terrain

A Germanwings Airbus A320-200, registration D-AIPX performing flight 4U-9525 from Barcelona,SP (Spain) to Dusseldorf (Germany) with 144 passengers and 6 crew, was enroute at FL380 about 30nm southeast of Marseille (France) when the aircraft initiated a rapid descent. Radar contact with the aircraft was lost at about 6800 feet at approx. 10:45L (09:45Z) about 12nm southwest of Barcelonnette (France), 75nm northwest of Marseille. The aircraft was found at approximate position N44.2979 E6.4670, all on board perished.

French Police reported two helicopter spotted the remains of the aircraft on the ground at about 2700 meters elevation (8800 feet) between Prads-Haute-Bleone and Barcelonnette (France), about half way between the two cities there is a mountain ridge rising up to 8900 feet.

The President of France reported, it does not appear there are any survivors. The crash site is very difficult to reach.

France's DGAC reported the crew transmitted an emergency call just prior to the aircraft disappearing from radar near Bassinet.

Germanwings and Lufthansa, parent company of Germanwings, confirmed flight 4U-9525 suffered an accident in the French Alps. There were 144 passengers and 6 crew on board. A hotline for family member was opened at Phone Number (Germany): 0800 11 33 55 77.

In a press conference about 4.5 hours after the aircraft disappeared from radar Germanwings reported 144 passengers, among them 2 babies, and 6 crew were on board. The aircraft reached its cruise level at 10:45L, one minute later the aircraft left cruise level and initiated a descent over 8 minutes. Radar contact was lost at 10:53L at about 6000 feet. The aircraft had been delivered by Airbus to Lufthansa in 1991 and had undergone all needed maintenance checks including a last check on Mar 23rd 2015, the last major maintenance check had been in Summer 2013. The captain had 6000 flight hours of experience. The airline received contradicting information from ATC France as to whether an emergency call had occurred.

France's Air Traffic Control reported there had been no emergency call from the aircraft. There had been confusion initially, Marseille controllers declared Mayday for the aircraft when they observed the aircraft below safe altitude.

The French Ministry of Interior reported in the afternoon, about 8 hours after the aircraft disappeared from radar, that a first blackbox has been found.

The French BEA reported they have dispatched seven investigators on site, a press conference is going to be held on Mar 25th 2015 at 15:00Z.

Germany's BFU have dispatched three investigators on site.

Radar data suggest the aircraft had reached FL380 about 3 minutes prior to leaving FL380 and descended from FL380 through FL110 in 8 minutes (average rate of descent 3375 fpm). The aircraft appeared to have levelled off at FL068 for one minute while on a northeasterly heading of 26 degrees true, mountains rise up to 8900 feet about 1nm north of the last reported aircraft position.

Aerial Overview of Crash Site (Photos: Alejandro Alvarez):

Helicopter Base for Search and Recovery Teams (Photo: French Ministry of Defense):

Map Crash Site (Graphics: France Gendarmerie Nationale):

The flow of information stopped, night had already fallen and it was obvious that the rescue work at the crash site would be interrupted until dawn. Unfortunately, there were no more lives to save.

I ended the "breaking news mode", which essentially meant that new information would be published as quickly as possible, but some of the cross-checks had to be omitted during the breaking news mode. I now caught up on these checks, and all the information published so far proved to be correct.

Other reports now came into play, and I turned my attention back to the BFU bulletin. Years later, I realized that this incident of 5 November 2014 would also play an important role in the investigation of the Germanwings crash. I wrote the following addition to my existing initial report:

Incident: Lufthansa A321 near Bilbao on Nov 5th 2014, loss of 4000 feet of altitude

On Mar 24th 2015 Germany's Bureau of Aircraft Accident Investigation (BFU) reported in their November 2014 bulletin, that the first officer observed an irregularity in the properties of the speed indication just prior to reaching FL310 and disengaged the autopilot, the aircraft in response began a descent that lasted for about one minute before the crew was able to stop the descent at FL270.

The BFU reported Spain's CIAIAC delegated the investigation to the BFU on Nov 11th 2014.

The BFU reported that according to flight data and cockpit voice recorder the first officer (35, ATPL, 6,473 hours total, 5,179 hours on type) was pilot flying, the captain (52, ATPL, 16,384 hours total, 12,414 hours on type) pilot monitoring. After the aircraft climbed clear of top of clouds at about FL200 the flight data recorder recorded a fixed value of +4.2 degrees for the left hand AoA sensor, less than a minute later the FDR began to record a fixed value of +4.6 degrees for the right hand AoA sensor. The aircraft subsequently turned to fly direct to LATEK waypoint, during this turn the captain noticed the Alpha Protection Band had unusually and significantly increased. The first officer therefore reduced the climb rate from 800 to 500 feet per minute to enable the aircraft to accelerate. A short time later the first officer disengaged the autopilot and gave a brief nose down input.

The aircraft however continued to pitch down, inputs to counter the pitch down remained without effect. About 45 seconds after the nose down began the first officer alerted the captain who took control of the aircraft, that at this time had reached a rate of descent of 4000 feet per minute and a pitch of -3.5 degrees. The captain provided a maximum nose up input which caused the aircraft to pitch up again and the rate of descent decreased and the aircraft entered level flight.

The captain was able to maintain altitude by providing a continuous nose up input deflecting the side stick about 50% of its travel. The autopilot could not be engaged again, and a manual nose up trim was not possible.

The crew checked for related checklists but did not find any. The crew reset the Flight Augmentation Computers 1 and 2 in sequence with no effect.

8 minutes after the aircraft began its descent the Aircraft Communications Addressing and Reporting System (ACARS) issued an automated information to dispatch showing the three AoA sensor values among other data.

21 minutes after the aircraft began its descent the crew sent a message to maintenance checking whether a simultaneous reset of all FACs would be possible. Maintenance replied in the positive stating that the aircraft would revert to alternate law as a result. Another 7 minutes later the crew reported they needed to constantly pull on the sidestick, trim was inoperative and autopilot could not be engaged and the Alpha Prot Band came up extremely quick. In addition the crew received a message "PH6 AOA3" on the centralized fault display system (CFDS). Upon suggestion by maintenance the crew switched off the air data reference unit (ADR3), however, without effect. ADR3 was reengaged. Another 12 minutes later maintenance wrote a message to the cockpit along the lines "after review of the data we found the values for AoA 1 and AoA2 appear to be frozen and report too high an angle of attack. If the problem persists, disengage ADR1 and ADR2 which will cause the aircraft to revert to Alternate Law however." then followed up "perhaps it is sufficient to just disengage ADR2".

The crew disengaged ADR2 which immediately prompted the aircraft to revert to Alternate Law and it was no longer necessary to pull the nose up.

The crew decided to use the remaining hour of flight time to verify the system status and to prepare for landing and landed safely at the destination.

The BFU reported that the aircraft features three Angle of Attack sensors consisting of a heated movable vane, the movement of the vanes is converted into electrical signals and the actual angle of attack computed by the related air data reference unit.

If the measured/computer Angle of Attack exceeds the value of Alpha Prot by one degree, the autopilot is automatically being disengaged. In manual flight if the Alpha Prot Angles is exceeded, the Alpha Protection activates, the position of trim is stored and used as maximum nose up trim, the function of the side stick changes to command a specific pitch angle with the most nose up angle being Alpha Max which can be reached by full nose up deflection of the side stick.

The BFU reported that all three AoA sensors were examined by the manufacturer, no damage, malfunction or anomaly was identified with either of the sensors.

Airbus analyzed the data and stated: "all three sensors worked normally until about 8 minutes into the flight, when the aircraft climbed through FL195. At that point, at an ambient temperature of -35 degrees C, AoA sensors 1 and 2 froze up at a position of approximately 4.5 degrees nose up and remained in this position until the aircraft descended towards the destination airport. At the time, when the autopilot disengaged the aircraft was flying at 0.675 mach, the Alpha Prot angle was 4.2 degrees, the Alpha Max 5.8 degrees. Within 15 seconds the first officer made increasing nose up input until reaching 75% of the maximum travel of the side stick, the attitude however changed from 4.5 degrees to -3.5 degrees against this input. The system disregarded/turned off the AoA 3 sensor because it disagreed more than the permitted value with the other 2 sensors.

When later ADR2 was disengaged, the system immediately reverted to Alternate Law because ADR3 had already been disengaged by the system and now two ADRs were offline.

The BFU reported that they are working to establish how reliable AoA sensors are but annotated: "The algorithms and boundary conditions differ from each other and are not entirely known to the BFU. The investigation is aiming to establish the probability of a repeat of this occurrence."

Graphical Representation of Flight Data (Graphics: BFU):

Further reports followed. I published the last report of the day at 23:58L and left the editorial office.

Chapter 2

The day after

Early in the morning, unusually early, I sat in my office again and worked my way through all the information that had come in during the night. Several small additions to our report followed, and I also began to organize our report by topic.

The French air accident investigation announced a press conference for 16:00L. I prepared everything so that I could follow the press conference live via the internet and add to our report live during the press conference, so to speak.

The press conference began and initially seemed to proceed normally, but it quickly became clear that something unusual was going on. The BEA was extremely closed to questions from the journalists present on site and gave very few details. When the BEA then completely stonewalled and announced that it was not allowed to disclose more, it was finally clear that the investigation did not classify the crash as an accident.

After the press conference, our report reached the following status at 17:13L (16:13Z):

Crash: Germanwings A320 near Barcelonnette on Mar 24th 2015, lost height and impacted terrain

A Germanwings Airbus A320-200, registration D-AIPX performing flight 4U-9525 from Barcelona,SP (Spain) to Dusseldorf (Germany) with 144 passengers and 6 crew, was enroute at FL380 about 30nm southeast of Marseille (France) when the aircraft initiated a rapid descent. Radar contact with the aircraft was lost at about 6800 feet at approx. 10:45L (09:45Z) about 12nm southwest of Barcelonnette (France), 75nm northeast of Marseille. The aircraft was found at approximate position N44.2979 E6.4670, all on board perished.

Search, Rescue and Recovery

French Police reported two helicopter spotted the remains of the aircraft on the ground at about 2700 meters elevation (8800 feet) between Prads-Haute-Bleone and Barcelonnette (France), about half way between the two cities there is a mountain ridge rising up to 8900 feet.

The President of France reported, it does not appear there are any survivors. The crash site is very difficult to reach.

On Mar 25th 2015 more than 300 policemen and 380 fire fighters departed Seyne-les-Alpes, the base for the search and recovery, to continue the recovery efforts, that were suspended during the night. Weather conditions are better than expected, no precipitation and less strong winds than forecast.

Statements, mainly to sequence of events

France's DGAC reported the crew transmitted an emergency call just prior to the aircraft disappearing from radar near Bassinet.

Germanwings and Lufthansa, parent company of Germanwings, confirmed flight 4U-9525 suffered an accident in the French Alps. There were 144 passengers and 6 crew on board. A hotline for family member was opened at Phone Number (Germany): 0800 11 33 55 77.

In a press conference about 4.5 hours after the aircraft disappeared from radar Germanwings reported 144 passengers, among them 2 babies, and 6 crew were on board. The aircraft reached its cruise level at 10:45L, one minute later the aircraft left cruise level and initiated a descent over 8 minutes. Radar contact was lost at 10:53L at about 6000 feet. The aircraft had been delivered by Airbus to Lufthansa in 1991 and had undergone all needed maintenance checks including a last check on Mar 23rd 2015, the last major maintenance check had been in Summer 2013. The captain had 6000 flight hours of experience. The airline received contradicting information from ATC France as to whether an emergency call had occurred.

France's Air Traffic Control reported there had been no emergency call from the aircraft. There had been confusion initially, Marseille controllers declared Mayday for the aircraft when they observed the aircraft below safe altitude.

The French Ministry of Interior reported in the afternoon, about 8 hours after the aircraft disappeared from radar, that a first blackbox has been found.

The French BEA reported they have dispatched seven investigators on site, a press conference is going to be held on Mar 25th 2015 at 15:00Z.

Germany's BFU have dispatched three investigators on site.

On Mar 25th 2015 France's Minister of Interior reported that the recovered black box was the cockpit voice recorder. The CVR is damaged but usable.

On Mar 25th 2015 the French BEA reported in a press conference, that the aircraft was following its planned flight path. After cruising at FL380 for a little while the aircraft began to descend at about 09:30Z. The last radar position recorded by French ATC was at 6175 feet MSL at 09:40:47Z very close to the point of impact. The aircraft impacted ground at very high speed.

Radar data

Radar data suggest the aircraft had reached FL380 about 3 minutes prior to leaving FL380 and descended from FL380 through FL110 in 8 minutes (average rate of descent 3375 fpm). The aircraft appeared to have levelled off at FL068 for one minute while on a northeasterly heading of 26 degrees true, mountains rise up to 8900 feet about 1nm north of the last reported aircraft position.

The cockpit voice recorder showing the force of impact (Photo: BEA):

Aerial Overview of Crash Site (Photos: Alejandro Alvarez):

Helicopter Base for Search and Recovery Teams (Photo: French Ministry of Defense):

Map Crash Site (Graphics: France Gendarmerie Nationale):

Detail Map (Graphics: AVH/Google Earth):

Radar Track (Graphics: AVH/Google Earth):

Infrared Satellite Image Meteosat Mar 24th 2015 09:00Z (Graphics: AVH/Meteosat):

On the evening of March 25, 2015 US time, the New York Times published an article:

Germanwings Pilot Was Locked Out of Cockpit Before Crash in France By Nicola Clark and Dan Bilefsky March 25, 2015Nicola ClarkDan Bilefsky

PARIS - As officials struggled Wednesday to explain why a jet with 150 people on board crashed amid a relatively clear sky, an investigator said evidence from a cockpit voice recorder indicated one pilot left the cockpit before the plane's descent and was unable to get back in.

A senior French military official involved in the investigation described a "very smooth, very cool" conversation between the pilots during the early part of the flight from Barcelona, Spain, to Düsseldorf, Germany. Then the audio indicated that one of the pilots left the cockpit and could not re-enter.

"The guy outside is knocking lightly on the door, and there is no answer," the investigator said. "And then he hits the door stronger, and no answer. There is never an answer."

He said, "You can hear he is trying to smash the door down."

While the audio seemed to give some insight into the circumstances leading to the Germanwings crash on Tuesday morning, it also left many questions unanswered.

"We don't know yet the reason why one of the guys went out," said the official, who requested anonymity because the investigation was continuing. "But what is sure is that at the very end of the flight, the other pilot is alone and does not open the door."

The data from the voice recorder seems only to deepen the mystery surrounding the crash and provides no indication of the condition or activity of the pilot who remained in the cockpit. The descent from 38,000 feet over about 10 minutes was alarming but still gradual enough to indicate that the twin-engine Airbus A320 had not been damaged catastrophically. At no point during the descent was there any communication from the cockpit to air traffic controllers or any other signal of an emergency.

When the plane plowed into craggy mountains northwest of Nice, it was traveling with enough speed that it was all but pulverized, killing the 144 passengers and crew of six and leaving few clues.

The French aviation authorities have made public very little, officially, about the nature of the information that has been recovered from the audio recording, and it was not clear whether it was complete. France's Bureau of Investigations and Analyses confirmed only that human voices and other cockpit sounds had been detected and would be subjected to detailed analysis.

Asked about the new evidence revealed in the cockpit recordings, Martine del Bono, a bureau spokeswoman, declined to comment. "Our teams continue to work on analyzing the C.V.R.," she said, referring to the cockpit voice recorder. "As soon as we have accurate information we intend to hold a press conference."

Meanwhile, prosecutors in Marseille, who have been tasked with a separate criminal inquiry into the crash, could not immediately be reached for comment. Brice Robin, the Marseille prosecutor, was due to meet Thursday morning with the families of the crash victims.

At the crash site, a senior official working on the investigation said, workers found the casing of the plane's other so-called black box, the flight data recorder, but the memory card containing data on the plane's altitude, speed, location and condition was not inside, apparently having been thrown loose or destroyed by the impact.

The flight's trajectory ahead of the crash also left many unanswered questions.

Rémi Jouty, the director of the Bureau of Investigations and Analyses, said at a news conference that the plane took off around 10 a.m. local time from Barcelona and that the last message sent from the pilot to air traffic controllers had been at 10:30 a.m., which indicated that the plane was proceeding on course.

But minutes later, the plane inexplicably began to descend, Mr. Jouty said. At 10:40 and 47 seconds, the plane reported its last radar position, at an altitude of 6,175 feet. "The radar could follow the plane until the point of impact," he said.

Mr. Jouty said the plane slammed into a mountainside and disintegrated, scattering debris over a wide area, and making it difficult to analyze what had happened.

It often takes months or even years to determine the causes of plane crashes, but a little more than a year after the disappearance of a Malaysian airlines jetliner that has never been found, the loss of the Germanwings flight is shaping up to be particularly perplexing to investigators.

One of the main questions is why the pilots did not communicate with air traffic controllers as the plane began its unusual descent, which suggested that the pilots or the plane's automated systems may have been trying to maintain control of the aircraft as it lost altitude.

Among the theories that have been put forward by air safety analysts not involved in the investigation is the possibility that a pilot was incapacitated by a sudden event such as a fire or a drop in cabin pressure.

A senior French official involved in the investigation, who spoke on the condition of anonymity, said that the lack of communication from the pilots during the plane's descent was disturbing, and that the possibility that their silence was deliberate could not be ruled out.

"I don't like it," said the French official, who cautioned that his initial analysis was based on the very limited information currently available. "To me, it seems very weird: this very long descent at normal speed without any communications, though the weather was absolutely clear."

"So far, we don't have any evidence that points clearly to a technical explanation," the official said. "So we have to consider the possibility of deliberate human responsibility."

Mr. Jouty said it was far too early in the investigation to speculate about possible causes.

"At this moment, I have no beginning of a scenario," Mr. Jouty said. However, he said there was not yet any evidence available that would support a theory of a depressurization or of a midair explosion.

Speaking on the French radio station RTL, Interior Minister Bernard Cazeneuve said Wednesday morning that terrorism was not a likely "hypothesis at the moment," but that no theories had been excluded. He said the size of the area over which debris was scattered suggested that the aircraft had not exploded in the air but rather had disintegrated on impact.

Lufthansa, the parent company of Germanwings, has characterized the crash as an accident. The airline has not disclosed the identities of the pilots, except to say that the captain was a 10-year veteran with more than 6,000 hours of flying time in A320s.

The French Bureau of Investigations and Analyses, which is leading the technical inquiry into the crash, sent seven investigators to the crash site Tuesday. They have been joined by their counterparts from Germany, as well as by technical advisers from Airbus and CFM International, the manufacturer of the plane's engines.

Speaking on Europe 1 radio, Jean-Paul Troadec, a former director of the French air accident investigation bureau, said one of the big challenges for investigators would be to protect the debris at the crash site from inadvertent damage.

"We need to ensure that all the evidence is well preserved," Mr. Troadec said, referring to the pieces of the plane littered across the steep slopes as well as to the remains of the victims. The identification of the victims will probably require matching DNA from the remains with samples from relatives.

The recovery effort will be a laborious task, given the state of the wreckage, the difficult terrain and the fact that the crash site is so remote that it can be reached only by helicopter.

Cabin depressurization, one of the possibilities speculated about on Wednesday, has occurred before, perhaps most notably in the crash of a Cypriot passenger plane in 2005 that killed all 121 people on board as it approached Athens. In that case, Helios Airways Flight 522, a slow loss of pressure rendered both pilots and all the passengers on the Boeing 737 jet unconscious for more than three-quarters of an hour before the aircraft ran out of fuel and slammed into a wooded gorge near Athens, the Greek capital.

Investigators eventually determined that the primary cause of that crash was a series of human errors, including deficient maintenance checks on the ground and a failure by the pilots to heed emergency warning signals.

Chapter 3

The "verdict" is announced 49 hours after the crash March 26, 2015

In the morning of Thursday, March 26, 2015 at 11:30L (10:30Z), just 49 hours after the crash, the public prosecutor of Marseille, Brice Robin, appeared before the international media at a press conference and announced that the captain of the plane had left the cockpit, the co-pilot of the plane (giving the co-pilot's name), now alone in the cockpit, had brought the plane into a suicidal descent and maintained the descent until it collided with the ground. Breathing noises were heard on the CVR and later screams were heard from the cabin.

The French gendarmerie and other forces that had been called in to recover the dead were at that point only busy searching the wreckage field in the difficult conditions of the mountainous terrain and locating the human remains and recovering the first human remains. In addition, the forces were trying to find the missing data module of the flight data recorder.

So how could the public prosecutor claim with such certainty, before the investigation had even really begun, that the co-pilot had deliberately crashed the plane? I was dismayed, I could not believe Brice Robin's statements and I certainly could not believe that a seasoned lawyer and public prosecutor would announce the result of the investigation before it had even begun. For me, this was an inadmissible prejudgement. However, it was and is the editorial principle of the AVH that my personal opinion has no place in my reports.

At 12:55L (11:55Z) after the end of the press conference, I therefore supplemented our report as follows:

On Mar 26th 2015 the States Attorney of Marseille (France) reported, the first officer was alone in the cockpit. The first officer was not talking, only normal breathing could be heard after the captain departed the cockpit. The captain was not able to get back into the cockpit. The first officer initiated a rapid descent, there was no reason to initiate the rapid descent, there was no reason to not communicate with air traffic control, there was no reason why the door wouldn't open. With the current information it can be said, that the breathing of the first officer is not consistent with someone suffering a heart attack or other health issue. Other than that there is absolute silence, screams are heard only in the last few moments. There were no words heard during the last 10 minutes of the flight. The attorney thinks the first officer intentionally did not open the door.

The Düsseldorf public prosecutor, Sta. Kumpa, had also issued an initial statement, which we summarized in our report as follows:

On Mar 26th 2015 the States Attorney of Dusseldorf (Germany) reported, that according to preliminary results by French Authorities only one pilot was in the cockpit at the time of the crash.

I was not the only one who was appalled and alarmed by the early pronouncement of the "verdict". For example, the German newspaper "WELT" reported in its article "Die seltswürdig schnelle Festlegung auf eine Wahrheit" from March 27, 2015:

Investigations into airplane accidents usually take years. In the case of the Germanwings crash, everything seemed clear after 48 hours. Investigators and pilots are outraged - and warn against drawing fatal conclusions.

The sequence of events contradicts all the rules of a neutral investigation into a plane crash. Less than 48 hours after Germanwings flight 4U9525 crashed into a mountain in the south of France, the exact sequence of events seems to have been established.

...

The French public prosecutor Brice Robin's decision to press ahead was triggered by a report in the "New York Times". Citing an unnamed French military source, the newspaper reported that there was only one pilot in the cockpit of the Germanwings A320 at the time of the crash.

The public prosecutor's version

Obviously the public prosecutor's office felt under pressure to react quickly and provided further details, thus giving direction . This advance was unusual. The public prosecutor referred to a transcript of the last 31 minutes of the flight. In the first 20 minutes, the two pilots had been talking to each other in a completely normal way.

On March 26, 2015, the German police carried out a search of the co-pilot's apartment and bedroom in his parents' house on behalf of the Düsseldorf public prosecutor's office. The public prosecutor reported at a press conference the following day that a torn sick note had been seized and that the co-pilot had reported for duty despite being on sick leave. We have summarized the press conference as follows:

On Mar 27th 2015 the States Attorney in Dusseldorf confirmed that the two homes of the first officer have been searched in order to find clues to the motives of the first officer. A medical certificate requiring sick leave has been found during those searches, the certificate was found torn, the first officer reported for the flight nonetheless.

The three calls on March 24, 2015 suddenly made sense. With the faulty keypad on the cockpit door, it became clear that no deliberate action was needed to deny the 2nd pilot re-entry into the cockpit. A non-reaction in the cockpit was sufficient to exclude the 2nd pilot from the cockpit. In the event of the pilot's inability to act in the cockpit, it was therefore impossible for the 2nd pilot to return to the cockpit. Was this the scenario?

At the same time, doubts arose. Why did the caller know so soon after the crash that this information could be so important? Was there already a "grapevine" within Germanwings at this time that the co-pilot had committed suicide? Were there efforts within the airline to make the co-pilot a scapegoat?

I usually only receive information directly from the airlines when there is fear. Fear for their own lives, which could be endangered by maintenance deficiencies, for example, or far too much stress to be able to move airplanes safely are already known causes of such "dam failures", as I call the phenomenon. Has a dam just burst within Germanwings as a result of the crash?

In the wake of the terrorist events of September 11, 2001 (also known as 09/11 nine/eleven), the American Federall Aviation Administration (FAA) decided to reinforce the cockpit doors so that terrorists would be safely denied access to the cockpit and pilots would therefore have the chance to retain control of the aircraft in the event of a new terrorist attack and to land the aircraft safely at an airfield, thus protecting the aircraft from being used as a weapon. However, the FAA did not make this decision without a risk assessment. Various scenarios were considered, including the possibility of the person or persons in the cockpit becoming unconscious and therefore requiring assistance from the cabin. This is why a simple bell button was not used, but instead the option was created to open the door automatically using secret emergency codes, even if there was no reaction in the cockpit. However, the FAA also considered scenarios such as a pilot running amok or even suicide. For this reason, the FAA stipulated in the accompanying rules that no pilot could be alone in the cockpit; the four-eyes principle had to be maintained from take-off to landing. So if one of the pilots had to leave, a flight attendant was to take his place in the cockpit, who would also be able to open the door on normal request for entry, i.e. to move the switch for the door from NORM to UNLOCK. This also ensured that a stroke or heart attack suffered by the pilot would not necessitate the use of the emergency code, thus increasing safety.

EASA, the European Civil Aviation Authority, however, did not share this last assessment on the basis of the argument "we trust our pilots". The four-eyes principle was therefore dropped from the European regulations. Has this assessment now fallen on the feet of those responsible? Would it have been possible to accuse the co-pilot of such an act if a second person had been present in the cockpit? Did this argument and dropped regulation make it possible to make the co-pilot of flight 4U-9525 the scapegoat? Did this trust lead to mistrust in the first place?

Only shortly before, on November 29, 2013, a captain of LAM Linhas Aereas de Mocambique had locked his co-pilot out of the cockpit, who had briefly left to go to the toilet, brought his Embraer ERJ-190 into a descent and maintained the descent until it hit the ground. According to information directly from the pilot's colleagues, the motive was clear within a few hours; the reasons for the desperate act lay in the captain's personal environment as well as in an incomprehensible decision by the LAM personnel office, which forced the captain to carry out the flight, although the captain legitimately wanted to sign off for the flight as "unfit to fly". Several of the captain's colleagues drew my attention to the captain's personal crisis as well as the decision of the personnel office and explained that such an act of desperation would almost certainly have been avoided in the future if the personnel office had accepted the "unfit to fly" declaration and appointed a replacement instead.

Was the scenario announced by the Marseille public prosecutor at the press conference possibly determined by the crash of the LAM 16 months earlier and did this crash obscure the investigators' view of other possibilities?

I decided to ask Lufthansa, which is also responsible for press relations at Germanwings. So I sent the following e-mail:

Quote:

Date: Mon, 30 Mar 2015 02:21:08 +0200

To: [email protected]

Bcc: Simon Hradecky <[email protected]>

Subject: Germanwings 4U-9525

X-Mailer: Virtual Access by Atlantic Coast PLC, http://www.atlantic-coast.com/va

Message-Id: <[email protected]>

Mime version: 1.0

Content-Type: text/plain; charset=iso-8859-1

Content transfer encoding: 8bit

From: Simon Hradecky <[email protected]>

Reply-To: [email protected]

X-VA-Origin: Avherald:Mail

Dear Ms. Schädler!

I can't tell you how much I was affected by the crash of the Germanwings D-

I am personally affected by AIPX and how difficult it is for me to accept the

professional distance for our reporting:

http://avherald.com/h?article=483a5651

to preserve.

However, I have received a bundle of information that in summary largely rule out a

suicide by the First Officer and render an

accident very likely ...

Can you confirm that the D-AIPX was dispatched from Barcelona to Düsseldorf under

MEL requirements with the Cockpit Door Keypad and Cockpit

Door buzzer out of order? If so, when was this defect added to the MEL

set?

Yours sincerely

Simon Hradecky

The Aviation Herald

http://avherald.com

End quote:

It is probably no surprise to anyone that the e-mail remained unanswered.

Chapter 4

The period from 27.3.2015 to 13.3.2016, the final report of the

Over the next few days, there were further statements, which we summarized as follows in our ongoing coverage:

On Mar 28th 2015 the Office of the States Attorney in Marseille reported, that the search for the flight data recorder is still ongoing. The office does not rule any scenario out yet including a technical problem of the aircraft, the social environment of the first officer is still being investigated. On Mar 30th 2015 the States Attorney of Dusseldorf stated in a press conference, that there is no evidence of any organic problem (specifically referring to speculation in media the first officer's eyesight might have been impaired). In the past, before acquiring his pilot's license, the first officer was in psychotherapist treatment for suicidal tendencies. Since then there is evidence of several visits to doctors, however, from then up to now there is no hint in the direction of suicidal or aggressive tendencies. The States Attorney is not able and not permitted to participate in speculation, he cannot state any more as a result. On Mar 31st 2015 the French BEA reported that the BEA investigation is continuing and is currently focussing on establishing the detailed progress of flight based on the cockpit voice recorder and other flight data, that may become available, as well as on identification of system weaknesses that possibly led to this catastrophe or similiar events. In particular the interest is directed at the locking mechanism logic of the cockpit door and the procedures to exit and access the cockpit as well as at criteria and procedures to detect specific psychological profiles. On Mar 31st 2015 Lufthansa explained, that the first officer told the airline in 2009, that he had been in treatment for a depressive episode. The e-mail exchange has been forwarded to the States Attorney in Dusseldorf. On Apr 2nd 2015 the States Attorney of Marseille announced, that the second black box, the flight data recorder, has been found and has been recovered from the crash site. On Apr 3rd 2015 the French BEA reported that the flight data recorder was received by the BEA on Apr 2nd 2015, it was opened and a first read out of the data showed, that the pilot in the cockpit used the autopilot to descend the aircraft down to 100 feet, on several occasions the speed of the aircraft was adjusted during the descent

After that, things went quiet. On May 6, 2015, the BEA presented a preliminary report that provided further details that reinforced the conclusions that the co-pilot had committed suicide and confirmed the picture that had emerged so far.

My doubts about the prejudice began to subside, even if I was still skeptical. In any case, I saw no reason to involve myself and AVH any further. The overall picture that had emerged so far seemed conclusive, and it seemed impossible for me to find a counter-argument based on the current state of knowledge.

I have seen in my more than 25,000 aviation incident reports, including many Air Accident Investigation Board final reports, that it is all too easy to blame the pilots for an accident. The interests of living people such as designers, maintenance engineers, manual authors, decision makers in aviation authorities and airlines etc. all too often gain the upper hand because it is often no longer possible for the pilots to defend themselves. I therefore always see pilots as the weakest link in the investigation chain. I therefore stand by the pilots until any misconduct has been proven beyond all doubt and other possible causes have been ruled out.

I said the following about this topic in an interview in 2012:

Only when we stop idealizing people and making demands on them that a person cannot fulfil in the long term and especially under pressure, only when we stop making the person in the cockpit, who is usually no longer able to defend himself against such accusations and is therefore the easiest target of accusations, the scapegoat and consistently investigate and present the causes of his "wrong decisions", will we be able to reduce accidents due to "human factors".

So as much as I was reluctant to "find a pilot guilty" without first having ruled out all technical causes and explored the reasons for his actions, I could no longer escape the impression of the developing overall picture and resigned myself resentfully.

Chapter 5

The final report of the BEA

On March 13, 2016, the BEA published their final report, which, after the previous press conferences and the preliminary report, no longer contained any surprises. I summarized the report at the AVH as follows:

Quote:

The French BEA released their final report concluding the probable causes of the crash were: 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. The following factors may have contributed to the failure of this principle: - 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; - 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.