The WORST Story I’ve Ever Told.. | Germanwings 9525
By Mentour Pilot
Summary
Topics Covered
- Rigorous Screening Misses Hidden Mental Cracks
- Career-Ending Clauses Deter Self-Reporting
- Depression Hits Pilots Like Everyone Else
- Cockpit Doors Trap Captain in Fatal Design Flaw
- Peer Support Fixes Self-Reporting Failures
Full Transcript
An Airbus A320 from the German lowcost company German Wings is cruising effortlessly through the upper airspace of Budau FIR heading towards the bustling Catalan capital of Barcelona,
Spain.
The flight is the first one of two earies on the 24th of March 2015. And so
far, this day has progressed just like any other. The two pilots had met up in
any other. The two pilots had met up in the crew room in Dusseldorf earlier that morning to review the pre-flight paperwork. And beside a few minor notes
paperwork. And beside a few minor notes in the aircraft's tech log, all the paperwork and flight plans looked absolutely fine. The weather was great
absolutely fine. The weather was great with only a few wisps of high altitude clouds over their destination and there seemed to be nothing else to worry about. The boarding had then flowed
about. The boarding had then flowed smoothly with their four cabin crew doing an absolutely great job as always.
Though at time 0601 UTC, German wings flight 9524 took off from runway 23 left in Dusselorf and started climbing southwestward initially towards Paris.
And that was then followed by the cruise segment at flight level 370, which had so far also gone off without a hitch.
But now, as the aircraft was getting closer to the calculated top of descent, the captain, a 34 year old with just under 6,800 total hours, decided that he needed to visit the restroom before the
approach. At this point, he had worked
approach. At this point, he had worked as a captain on the Airbus A320 for a little less than a year, gaining about 259 hours of command experience on it.
but he used to also fly it as a first officer in another airline before moving over to the Airbus A330 and A340 for Lufansza back in 2010. After that he
eventually received his upgrade on the Airbus A320 in German wings which was a wholly owned subsidiary of Lufansza.
Now, all of that previous experience had taught him that it was better to go to the toilet before getting into the descent because skipping that would almost always mean that you would end up
in a holding pattern over the destination wishing that you'd gone.
Now, the captain was operating as pilot flying at this point and he had already completed the approach briefing into Barcelona, so he likely figured that there should be plenty of time. On top
of that, his 27year-old first officer with around 920 total hours seemed more than capable of holding the fort, even if they would have to start the descent
a bit early while he was away. So, the
captain now handed over the controls to his first officer, called up the cabin crew to alert them that he was about to come out, and he then checked the little screen to his left, which was connected
to cameras outside in order to make sure that the coast was clear. You can never be too careful.
Once that was all done, he slid his chair backwards, stood up, and then promptly left the cockpit, whilst also making sure that the reinforced cockpit door locked properly behind him with a
reassuring clink.
The first officer was now alone in the cockpit, glancing out of the mighty Pyrenees, which were stretching across the entire lower part of his windscreen all the way out into the blue
Mediterranean Sea. And then beyond that
Mediterranean Sea. And then beyond that lay Bles, Girona, and Barcelona shrouded in the misty distance.
Now, this is a site that I have seen hundreds of times before. So, I can really picture what he was seeing in my mind as I'm telling you this. The
arrival track that German Wings 9524 was now about to fly actually goes straight over the house where my family and me lived at the time.
Anyway, about half a minute after the captain had left the flight deck at the time 0720 and 29 seconds, the flight was then transferred over to the next Budauor frequency. And once the first
Budauor frequency. And once the first officer called them up, he was immediately instructed to descend down to flight level 350 or 35,000 ft.
He read this back, set flight level 350 on the autopilot's flight control unit, and then initiated the descent. But then
suddenly 20 seconds later, the selected altitude was rapidly changed down to only 100 ft, which is the lowest value that could be selected.
Another 3 seconds passed before the value quickly then changed up to 49,000 ft, the highest possible value, and then down to 35,000 ft again, where it stayed.
Another half a minute passed before Budauor control again called them up and asked the flight to descend further down to flight level 2110, which the first officer correctly read back and also
initially set, but only 1 minute and 11 seconds later.
The selected altitude again dropped down to 100 ft and it would then stay around there moving slightly up and down for a short while. That was until it finally
short while. That was until it finally was set back to the cleared altitude of 21,000 ft at the time 07 24 and 13 seconds. 2 seconds before the captain
seconds. 2 seconds before the captain entered the code to be let back into the cockpit.
4 1/2 minutes had passed since he left.
And during that time, an internal battle had likely been fought in the cockpit. A
battle where Sans had finally won, but not by a big margin. and a fight of which the captain, passengers, and cabin crew obviously had no idea. Now, this
was the terrifying beginning of a story that I have resisted to tell you for years simply because I couldn't find a way to leave you, my viewers, with a positive twist on it, or indeed any way
to show that the industry has become safer and better as a result.
But I have now decided to tell you this story anyway because I feel that even though there have been some improvements, there are still a lot left to be done. And we will need your help
and crucially also your understanding in order to do so. And the only way to earn that understanding is by making you see this.
The man who was fighting his demons alone in that cockpit was, like I mentioned, 27 years old and had at the time been working for German Wings since 2011.
During the first 2 and 1/2 years, he had been contracted as a cabin crew. But
already when he started in that role, he was actually licensed as a commercial pilot, just waiting for his chance to get into the cockpit.
Exactly like me, flying had been a lifelong dream for him and he had during his teen years been plastering his boyhood room with posters of Boeings and
air bosses often in Lu Hansa liveries.
As soon as he could, he then started flying gliders, which he allegedly became really good at. And meanwhile, he was doing very well in school and was eventually voted third most orderly in
his graduating class of 2008, which is a very German thing to vote on, by the way. In 2008, he then applied to the
way. In 2008, he then applied to the Lufansa Flight Academy, which is a partially self-funded academy with fierce competition. Only around 5% of
fierce competition. Only around 5% of the applicants are normally admitted after grueling interviews, suitability tests, and psychology evaluations. And
the first officer in this story ended up being one of those 5% who were finally invited to join. Now, I want to stop here and point something out. The fact
that he was selected even after this type of competition actually proves something that I think is very important. You see, from the very first
important. You see, from the very first videos that I made on this channel, I have been a strong advocate of thorough and fair pilot suitability testing.
There are personality traits that are not compatible with the pilot occupation. And the only thing sadder
occupation. And the only thing sadder than being told that you won't be able to get a job as a pilot when you apply for a flight school is being told that
very same thing after you've paid around $100,000 in training. But in the case of this first officer, that was not the case. He managed to get through a very
case. He managed to get through a very tough selection with no one picking up any personality traits or weaknesses that would make him unsuitable for the job. So for anyone out there advocating
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Now, let's get back to the first officer.
In any case, receiving the news that he had been accepted must have been one of the happiest days of this first officer's life. I clearly remember when
officer's life. I clearly remember when I received that phone call myself informing me that I had been accepted into the government sponsored pilot program in Sweden. And the feeling,
well, it just cannot be described in words. So said and done in September of
words. So said and done in September of 2008, the first officer joined up with around 200 other lucky candidates to start a theoretical part of their training towards becoming airline
pilots. Now it should be mentioned here
pilots. Now it should be mentioned here that this program whilst being partially funded by Lufansa still required the candidates to pitch in around €60,000 or
$70,000 of their own money to allow them to participate. And in the case of the
to participate. And in the case of the first officer, he covered this via a private loan plus savings. most likely
from his family, but I don't have the exact details of that. In any case, that is a lot of money, which in itself would have put him under quite a lot of pressure to perform well during this
training. Something that I think that a
training. Something that I think that a lot of pilot students out there will definitely recognize.
Now, part of the very first things that you need to do before starting your pilot training is to go through an initial medical examination, which is typically done at an AMC, an aeromedical
center. There, everything from your
center. There, everything from your vision to heart and lung function will be tested. And this first officer also
be tested. And this first officer also went through all of those tests without any kind of problems or restrictions.
But the following few months of theoretical training away from home then turned out to be very tough for him.
According to an article in GQ, the combination of missing his family and him putting unrealistic pressures on his own performance soon led to the first officer starting to develop psychosomatic physical symptoms like
tinitus for example which is a high-pitched ringing in the ears often associated with depression. Now, this
became so bad that it caused him to drop out of the course and return home to his parents already in November that same year. And a few months later, he
year. And a few months later, he consulted a psychiatrist who diagnosed him with a deep depressive episode, including suicidal thoughts. And he
therefore also prescribed him with two powerful anti-depressants, cyprollex and mtisipine, as well as intensive psychotherapy.
Now here this story could have ended but to believe that would mean that you haven't experienced the kind of deeprooted passion that the dedication to flying really is. A psychologist that
I spoke to explained that particularly in adolescent boys, this passion is often ignited by a specific moment when they maybe see and hear an aircraft
landing or takes part in a powerful experience like in my case when I got a test lesson for my 14th birthday. And
because that is often associated with positive stimuli in many parts of the brain at once, this passion becomes rooted deep inside the person's psyche and is therefore almost impossible to
get rid of. Those of us that are affected by this refer to it as becoming bitten by the bug and I definitely can attest to its almost unreal power.
So even though his initial medical class one certificate was revoked during this time of mental illness, giving up was likely not part of his vocabulary.
Instead, he kept fighting with his depression. And over the months that
depression. And over the months that followed, his psychiatrist also saw some steady progress. This led him 6 months
steady progress. This led him 6 months after having started the treatment to write a letter to the German aviation authorities saying that the first officer had now fully recovered and should therefore be allowed to restart
his training.
But obviously things weren't that simple. First of all, there are strict
simple. First of all, there are strict rules for how long a person who has been using psychiatric drugs needs to have been off medication before they are allowed to resume any flying activities.
And that's because it takes a while for the brain to readjust from some of these meds. And during that time, the person
meds. And during that time, the person might still be experiencing symptoms and therefore obviously shouldn't be flying.
So when the first officer applied to renew his class one medical on the one-year expiry date, it was initially refused. And here I will get to one of
refused. And here I will get to one of the biggest issues that I have with this whole story. You see, the German
whole story. You see, the German aviation authorities eventually did give the first officer back his medical certificate, as they should, but they then also added a note in this
certificate saying, "Note the special conditions/restrictions of the waiver 091-09 REV."
REV." And what a medical doctor would see if they looked up these special restrictions would be that any relapse into depression would render the medical
certificate permanently invalid and therefore effectively end his career.
Now at the face of it and especially in view of what ultimately happened, this seemed like quite a logical restriction, right? Well, if you take some time to
right? Well, if you take some time to think a little bit, you will quickly find that this logic starts to falter.
And let me explain why.
Imagine being in a position where you have worked your entire life towards a singular goal and then finally managed to achieve it. To get there, you have put all of your heart and soul into it,
but also a big chunk of your family's money, and you now cannot see yourself doing anything else. But then you get tennis elbow or something else that cannot be seen from the outside by
anyone but if diagnosed by a doctor will stop you from continuing to do what you love. But you are a good upstanding
love. But you are a good upstanding person. So you report it anyway and get
person. So you report it anyway and get put on leave until you have sorted it out which you finally do. But when you return you get told that if you ever notice any symptoms of tennis elbow
again your dream will be permanently lost. Would you then report it if it
lost. Would you then report it if it reappeared?
I think not.
And that's very important to remember as this story continues.
On the 26th of August 2009, the first officer then restarted his training and a little over a year later, he successfully completed the theoretical part, which meant that it was time to go
over to Arizona in the United States for the practical flying part. And here we come to the next hurdle where the saga could have been stopped. You see, in order for him to fly in the United
States, he also needed an FAA medical certificate. And when you apply for one
certificate. And when you apply for one of those, you have to fill in your medical history. One of the questions on
medical history. One of the questions on that form asked if he had suffered from any previous mental illness. And to
that, the first officer allegedly answered no. Now, lying on an FA
answered no. Now, lying on an FA application form is a federal offense that could, if brave enough, put you in jail and definitely stop you from flying, but someone here either in the
flight school or somewhere else in the chain that handled these forms must have caught and corrected this or someone pointed it out to him, you know, that
his history was verifiable and therefore got him to change that form. Again, this
is info that comes from outside of the official final report, but I think it's important to include, and I also want to point out another thing here. You see,
it is allegedly incredibly common for people to lie on these forms to avoid getting into lengthy issues with the licensing authorities. There exists a
licensing authorities. There exists a widespread feeling among both active pilots, instructors, and students that being 100% honest on these forms can put
you in a world of hurt where you sometimes need to jump through a lot of administrative hoops for seemingly no reason at all. So to avoid that, people
just lie instead, which is another thing that we as an industry really need to address because this issue is still persisting to this day.
Anyway, after this form had been updated to reflect his actual history, the FAA chose to initially not issue a class one medical. Instead, they asked him for
medical. Instead, they asked him for more information from his doctors. And
when he provided that, after some throwing back, the class one was finally issued. And that allowed the first
issued. And that allowed the first officer to start his practical training in the United States. But it can still be debated if this initial dishonesty was a sign of things to come or just
something that he had been advised to do in order to avoid trouble.
In the United States, everything seemed to have progressed fine. And from early in 2011 and onwards, the first officer came back to Germany and continued his flight training whilst also working as a
Luansa cabin crew. During those
following years, his class one medical was repeatedly extended without any issues. He felt fine and there were no
issues. He felt fine and there were no relapses back into depression. So from
September to December of 2013, he completed his type rating on the Airbus A320 and was subsequently hired to start his line training with German wings, flying short to mediumh hall routes all
over Europe.
On the 28th of July 2014, the first officer received his last medical certificate valid for a year, still with the same restriction printed on it. And
around the month before that, he had also passed his simulator proficiency check, meaning that he was now officially employed as a first officer on the Airbus A320.
Now, this should have been the first real high point in his career, but instead, it seems like his previous issues with fear of failures and putting unrealistic goals on himself might have started to percolate up again here. You
see, working as an airline pilot means that you are constantly being evaluated through simulator and line checks. And
as a first officer, you should always be striving to become better in order to finally upgrade to a captain in a few years. So the pressure is basically
years. So the pressure is basically always on.
Now throughout the general populace, around 5% of men and 7% of women will suffer from some form of depression during their lifetime. This obviously
varies in severity and form, and it also likely vastly is under reportported due to the stigma that is still attached to it. But we also know that depression is
it. But we also know that depression is treatable just like most physical illnesses are. So in my mind there is no
illnesses are. So in my mind there is no reason why these illnesses should be treated in a vastly different way. In
aviation the authorities grade different ailments on their likelihood to cause pilot incapacitation during critical phases of flight. And the consensus is that a condition cannot be accepted if
it increases that risk over 1% for a pilot over the course of a year which is known as the 1% rule. Now due to the inherent trickiness in evaluating
ecapitation due to mental illness and the very poor data set for statistics due to the stigmas involved, authorities have historically chosen to air on the side of caution here and therefore not
allow pilots with these issues to fly at all or at least severely restrict them.
But that is basically like sticking your head in the sand and pretend that it's not raining. Like I said before,
not raining. Like I said before, statistically we know that about 6% of the population will suffer from some form of depression during their lifetime. And that rises to around 12%
lifetime. And that rises to around 12% if you count in all forms of mental disorders. So do you think that pilots
disorders. So do you think that pilots are any different? No. Of course we're not. And that means that there has to be
not. And that means that there has to be ways for pilots to honestly raise their hand and say that they're not feeling well, get treatment, and then have a clear path back to the flight deck once
they are feeling better, or at least a financial backup plan if they want. But
this first officer had none of those.
As the old familiar symptoms started crawling back, he knew that his career would likely be over if he let the aviation authorities know about them. So
he initially likely kept them completely hidden and just carried on. None of the captains who flew with him during this time said that he had shown any signs of not feeling well. He was also in a
stable relationship. He ran half
stable relationship. He ran half marathons on his spare time and was planning to start a family.
But then around December of 2014, he suddenly started having issues with his eyesight. He contacted eye doctors
eyesight. He contacted eye doctors complaining about seeing stars, halos, and having double vision. But even
though he went through extensive testing, no doctor could ever find anything physically wrong with him. I
should also mention here that having vision problems is one of those things that scares us pilots the most. Together
with heart problems, these are the kind of conditions where we know that the margins to losing our medical is very thin. So these vision problems were
thin. So these vision problems were likely the psychosomatic representation of his deeprooted fear of failure flaring up again. Now the doctors soon
started catching on to this fact and one neurologist actually diagnosed him with hypochondrical disorder but the first officer initially rejected any insinuation of a psychological route to
his symptoms. In fact, he just broke off treatment as soon as it was mentioned, which knowing what we know now, makes kind of sense. His family doctor around
this time even diagnosed an emergent psychosis and urged him to check himself into a psychiatric clinic, but the first officer just ignored that. Now, I have a
question for you. Do you think that this would have happened if this man didn't associate a diagnosis like that with the end of his career and dreams? Remember,
he had already stopped and gotten himself treatment once before, but now it was obviously different. I also want to note here that German Wings actually had issued him with a loss of license
insurance that would be triggered in case of his permanent loss of medical fitness. That insurance would cover his
fitness. That insurance would cover his training costs, but nothing else. no
cover of his livelihood in any form since he was still below the 35-year-old threshold when this kind of policy could be extended to include that. And when he applied for a private insurance to cover
that part, it was denied due to his history of depression. So, you see the problem.
We're now getting to the really critical part of this story where this person falls deeper into the black hole that a mental illness can produce and therefore might not have been able to make
rational or logical decisions anymore.
This is where the personal safety nets and society at large needed to be able to step in and take over. But sadly that also now spectacularly failed. In
January of 2015, just months before flight 9525 was due to take off, the first officer's mother reached out to the same doctor that had previously treated him and asked him for help. At
this point, the first officer seemed to have accepted that the symptoms might be due to deeper psychological issues. So,
he actually volunteered to go back to this doctor who quickly recognized that his depression had now clearly returned.
This was therefore the trigger point for his permanent loss of license. But in
Germany, for that to happen, it would require the subject himself to report this to the authorities. Now, there were laws in place that would allow a physician to contact the authorities if
there was obvious risks to the person's well-being or the well-being of others, but there were also other laws around doctor patient confidentiality. And in
Germany, breaching those laws could put the doctor in jail. In any case, the first officer was now prescribed psychiatric medicines again, mortasipene
and laorasipam. And following his
and laorasipam. And following his doctor's orders, he started filling in a diary of happy thoughts designed to improve his view on the world. From that
diary, we can see that he was suffering from insomnia as well, which seems to have gotten better from the treatment, but his general depression did not. The
final report doesn't go into great details, but according to other sources, by early March, he had started to search the internet with phrases like producing
carbon monoxide, drinking gasoline, and which poison will kill without pain. On
the 10th of March, his doctor then diagnosed him with a possible psychosis and recommended psychiatric hospital treatment, which he promptly ignored, but he did accept further
anti-depressant and sleeping medication.
Eight days later, another physician wrote out a sick leave note for him due to persistent vision disorder with unknown origin. And the first officer
unknown origin. And the first officer actually did use several doctor's notes to motivate sick leave during this period. But he also ignored many others
period. But he also ignored many others and instead kept flying.
And none of his doctors said anything, neither to the authorities nor to his employer. And that's even though some of
employer. And that's even though some of them must have known what he did for a living. Then on the 20th of March, his
living. Then on the 20th of March, his suicidal thought seems to have taken a truly dark turn. And from here on out, the investigation shows that he now started searching the internet for
information about the locking mechanism for the Airbus A320's bulletproof cockpit door. 2 days later, he scribbled
cockpit door. 2 days later, he scribbled decision Sunday as well as BCN, the Yata code for Barcelona airport on a piece of paper that was later found in a trash
can in his apartment. Under that header, he had also added, "Find the inner will to continue to live, deal with stress and sleeplessness, and let myself go."
Now, I really want to emphasize here that this is not something that should be considered part of a normal depression, even with suicidal tendencies.
In fact, according to the research that I've done, most people who are considering suicide are actually deeply empathic and want to spare others pain as much as possible. So for this man to
start planning a mass murder suicide shows that something darker was in play here. Maybe he was angry at his employer
here. Maybe he was angry at his employer or the state for some reason. Or maybe
he just wanted his name to be remembered. We will never know. But I
remembered. We will never know. But I
think it's important to point out that there's nothing that can defend his line of thinking here nor how it continued.
On the following day, he had a standby duty from which he was called to operate a return trip between Disseldorf and Berlin. And the captain who flew with
Berlin. And the captain who flew with him on that day is said that he seemed perfectly fine. There seems to have been
perfectly fine. There seems to have been no outward signs of his demons that he was obviously dealing with, nor of the medication that he was taking to cope.
When he came home that evening, he went shopping with his girlfriend for the week ahead, and she later testified that she didn't notice anything special with him at all. Anyway, he then went to bed
in order to get up early for the flight to Barcelona the following morning, the 24th of March, 2015.
And this brings us back to that Airbus aircraft descending down over the Pyrenees on its initial approach into Barcelona.
Now, I don't have much details about the rest of this first flight, but we do know that the aircraft was eventually vetoed in for a landing on runway 07 left and that it taxied into their stand
at terminal 2. Once there, all of the inbound passengers disembarked as normal, not knowing just how lucky they were. The cabin crew then started
were. The cabin crew then started cleaning the cabin and doing their safety checks whilst the captain did his walk around and the first officer started setting up for the return trip.
German wings flight 9525 back towards Dusseldorf and on this leg he was going to be pilot flying inside the terminal building the
outgoing 144 passengers were now queuing up in order to board a whole school class with teenagers who had been on an exchange trip with a class in Barcelona
a famous opra singer and her husband moms dads toddlers and also the husband of a friend of my wife all excited about the trip ahead, all for different
reasons. And it actually breaks my heart
reasons. And it actually breaks my heart just to think about it. These were
completely innocent people caught up in what would soon become a true nightmare.
Anyway, at some point during the disembarkcation, one of the cabin attendants told the captain about the problem with the off toilet. Apparently,
it wasn't flushing. So, the captain called up the German Wings maintenance control center and asked for some advice.
They told him to try and reset the circuit breaker, but to do that, he would have to wait until all passengers were off in order to go back down to the back of the plane and follow their
instructions. This ordeal slowed down
instructions. This ordeal slowed down the subsequent boarding process quite a bit. So, when the aircraft finally left
bit. So, when the aircraft finally left the gates, it did so with a 26-minute delay. But according to the cockpit
delay. But according to the cockpit voice recorder, the mood in the cockpit still seemed completely normal with all standard checks and procedures being
adhered to. So at the time 0900 UTC or
adhered to. So at the time 0900 UTC or 10 local time, the gleaming 24year-old Airbus A320 took off from Barcelona's runway 07 right and started climbing
towards the northeast out over the blue Mediterranean Sea. The weather was still
Mediterranean Sea. The weather was still beautiful, so the first officer hand flew the aircraft for the first 3 minutes before engaging the autopilot in climb and nav mode. The captain was
handling the radio where they received progressive climb clearances for the next couple of minutes. At that time 09 12 and 15 seconds the buzzer in the cockpit sounded indicating that someone
wanted to get in. The captain checked his screen to see who it was. And when
he saw that it was one of the crew, he used the access button on the center pedestal to unlock the door and let the flight attendant in. During the
following minutes, the captain and the attendant discussed the delay and likely how they were going to report it. You
see, airlines keep extensive check on the reasons for delays. So try and find patterns and reduce them. So the crew often lies with each other before filling in the delay codes to make sure
that they agree on the reason. During
this conversation, the captain also mentioned that he had been too busy to go to the toilet during the turnaround, something that's quite common on short hall turnarounds when crews are pressing
to minimize delays. So he told the flight attendant that he would soon come outside again. And when the first
outside again. And when the first officer heard that, he cut into the conversation and said that the captain could go whenever he wanted.
But the captain preferred to wait until the aircraft was safely established in cruise first, which makes absolute sense.
Shortly after this conversation, the flight attendant left the cockpit and the two pilots continued to discuss how they were going to record the delay.
Soon they were also cleared to climb to their planned cruise level of 38,000 ft which they then reached at time 09 27 and 20 seconds. At this point they were
in contact with Merc and route control on frequency 133 decimal 330. But only 2 minutes later they were then transferred over to the next controller on frequency
127 decimal 18. The captain read this back, switched over the frequency, and then called up this new controller who answered with a standard Bunjourul German Wings 18 Golf. Proceed direct to
earmar, which was an orn of waypoint further down on their planned route.
Uh, direct merci German wings 18 Golf, answered the captain. And that would be the last radio message that would ever be heard from flight 9525.
The captain now told the first officer that he intended to go back to the toilet again and he then handed over the radio to him. He also told him to start preparing for the descent briefing while he was gone. Because even though this
was an almost 90 minutes long flight, the controllers often start descending flights a little bit early when they're coming from this direction in order to fit him into the busy German airspace.
And to that instruction, the first officer allegedly responded with an in hindsight quite ominous. Hopefully,
we'll see.
Now, the reason I'm saying allegedly is because the cockpit voice recorder transcript from this flight has never been publicly released. So, the reason that we know any details of what was actually said is because of various
sources who were allowed to be present during the screening of the CVR, including a few journalists and families of the passengers.
In any case, as the captain started sliding his seat back to get out, the aircraft started a slow turn towards Idmar as instructed. And at times 0 9:30 and 24 seconds, noises of the cockpit
door opening could be heard and then finally the door closing with a mechanic click. The first officer was now once
click. The first officer was now once again alone in the cockpit. This time
with the Alps stretching out in front of him. Before I continue, we need to talk
him. Before I continue, we need to talk a bit about the cockpit door that was now separating the first officer from all of the other 149 people on board.
After the horrific terrorist attacks of 9/11 in the United States, the consensus in the industry became that a stronger barrier needed to be installed to protect the cockpit from bad actors who
might once again try to use commercial aircraft as weapons. Before that,
hijackings had been sometimes violent and deadly, but not on the scale that those terrorist attacks had shown possible. So, something now had to be
possible. So, something now had to be done. Now, obviously, I won't be able to
done. Now, obviously, I won't be able to go into the intricacies of cockpit security here, nor the procedures that flight and cabin crew use, which actually also differs between airlines,
but I can tell you what's freely available and described in the final report. The security door that was
report. The security door that was installed on this Airbus A320 was made out of a composite sandwich type structure consisting of preer sheets
covering a honeycomb core. The outer
layer was designed to ensure bulletproofing. And needless to say,
bulletproofing. And needless to say, this door was made specifically to keep people out of the cockpit. It opened
towards the inside of the cockpit and would then be kept locked during flight with an electric lock. But obviously
there were still situations where someone might need to be able to get into the cockpit during flight. So to
enable this there was also a 12key keypad on the outside of the door which could be used to enter several different codes depending on the situation.
Normally there would be an access code which could be entered to let the pilot know that someone wished to enter similar to a doorbell of sorts. And when
used, it would then activate a buzzing sound in the cockpit for one second. If
that happened, the Airbus A320 pilots should then check a side screen that activated a couple of cameras outside of the door to verify who wanted to enter and of the situation. If the pilots then
chose to allow that person to enter, there was a toggle switch on the central pedestal where the pilots could choose to either unlock or lock the door. To
unlock it, the switch had to be held in the unlocked position, which illuminated a little green diode outside indicating that the door was now unlocked. And if
the switch was then released back to the norm position, the door would automatically lock again. But, and this is important, if the pilots would deem that there was a threat outside, well,
then they could also choose to lock the door. If they did that, this would show
door. If they did that, this would show a red diode on the panel, indicating that the door would remain closed, and that action would also disable the
keypad panel for 5 minutes. But of
course, the door could still be unlocked by the pilots by manually moving the toggle switch to unlock in case that lock selection had been chosen in error.
On top of this, there was also an emergency code that could be entered if, for example, pilot incapacitation would be suspected. And if that code would be
be suspected. And if that code would be used, the acoustic buser would sound continuously for 15 seconds inside of the cockpit. Then if there would be no
the cockpit. Then if there would be no response from the pilots inside, at the end of those 15 seconds, the door would automatically unlock. But again, it is
automatically unlock. But again, it is super important to note that this sequence could also be stopped by the pilot again by moving the toggle switch to lock. And if that happened, the same
to lock. And if that happened, the same thing would happen outside as I just explained, and the door would remain locked.
The whole idea with this door was to leave the last word about who could enter the cockpit to the pilots inside.
And this system was obviously built with the explicit thought of all major threats coming from the outside, not the inside.
Now, early on during the implementation of these new doors, many companies saw the weakness with this and therefore implemented a two qualified person minimum in the cockpit. This meant that
in case of one pilot having to leave their station, a qualified cabin crew would get in and sit on the jump seat with the door locked until that pilot returned. Now, this was more of an
returned. Now, this was more of an incapacitation feature than a barrier against bad actors in the flight deck.
It was done primarily to facilitate quicker help in case the remaining pilot would get sick. But not all airlines adopted this rule. Some of them saw bigger security threats in allowing more
people access to the cockpit, whilst others just didn't see the benefit of it. And German Wings was one of those.
it. And German Wings was one of those.
So with that in mind, let's now get back to the cockpit of flight 9525, where the true nightmare was now just about to start.
Only about 20 seconds after the captain had left, the selected altitude on the flight control unit changed again down to 100 ft. And immediately after that, the aircraft went from maintaining its
cruise altitude to an autopilot mode known as open descent, in which the engines will reduce back to idle thrust and the autopilot will pitch down as much as needed in order to maintain the
commanded speed.
This meant that the aircraft immediately left flight level 380 and started descending down towards its new commanded target. Now, the captain would
commanded target. Now, the captain would have definitely have noticed this from the toilet as the engine noise and angle of the aircraft would have shifted quite substantially. And my guess would have
substantially. And my guess would have been that he likely thought that this was strange, but not outside of the norm since we sometimes do get asked to change our cruising altitudes in order
to facilitate traffic flow.
44 seconds later, the cockpit voice recorder also picked up the sound of a pilot seat moving, indicating that the first officer was definitely still active at this point. so he wasn't
incapacitated.
The aircraft then continued to descend initially without anyone in air traffic control seemingly noticing this, but that would soon change. Now, this
aircraft was equipped with something known as a mode S transponder, which on top of transmitting its location and altitude, also can transmit certain selections from the autopilot flight
control unit in order to increase the controller situational awareness. that
would have included the selected altitude, but the hardware that the Marseilles controllers were using at the time had not yet been upgraded to receive that info. At time 0933 and 12
seconds, the speed management then changed from managed to selected, meaning that instead of using the speed recommended by the aircraft flight management system, it now switched over
to whatever was selected on the FCU. So,
the first officer was now actively inputting on this panel.
He started by increasing the speed from 273 to 308 knots. And the effect of that was that the aircraft now lowered its nose in order to increase the speed.
This meant that the vertical speed went from 1,700 to 5,000 ft per minute. And
it then settled back to around 3,500 ft per minutes when the new target speed had been reached. And the reason that this is important to point out is because this again shows that the first
officer was active and awake here. And
also that these speeds are nowhere near the speeds that we normally use for an emergency descent, for example. So this
did not look like any type of emergency response. On top of that, there were
response. On top of that, there were also no indications on the flight data recorder of any abnormal pressurization changes, nor was the oxygen mask in the cockpit activated. So any type of
cockpit activated. So any type of hypoxia can also effectively be ruled out.
Throughout this whole time, the steady breathing of the first officer could also be heard on the cockpit voice recorder. And we know that this was his
recorder. And we know that this was his breathing because it was later matched up with the same sound when the captain was still present in the cockpit and talking.
About 30 seconds after that higher speed had been selected, it was then decreased again to 288 knots, meaning that the vertical speed now slightly decreased.
And following that, the speed was then changed again six times until it finally stabilized at 302 knots and stayed there for a while. Now, it's hard to know why
the first officer was doing this. Maybe
he was still struggling with his horrible decision, or maybe he just wanted to mask his intentions from the subsequent investigation. We would never
subsequent investigation. We would never really know. But one thing that I think
really know. But one thing that I think that we can say with confidence is that from the moment that this aircraft had started its descent, he was likely determined to go through with his
monstrous plan. And then for every
monstrous plan. And then for every second that the aircraft continued to deviate from its cleared altitude, the fear of what the consequences would be for what he had already done would have
likely reinforced that determination. So
in his mind, there was likely no turning back anymore. A lot of people have asked
back anymore. A lot of people have asked how someone could make such a decision to decide to end not only his own life but also 149 others and destroy the
countless lives connected to them. And
obviously there's no good answer to that.
By time 0933 and 47 seconds the Marseilles controller had noticed that the aircraft was deviating heavily from its cleared level and he therefore called the flight up asking what cruise
level they had been cleared for. Now,
that's a typical phrase used when the controller knows that a mistake has been made, but when they still think that it's might be just that, a mistake or a misunderstanding.
Maybe the flight had mistaken a descent clearance for another flight as their own or something. But there came no reply back from flight 9525.
And at this point, it had already descended through 30,000 ft while still following its lateral clearance toward.
now more than 8,000 ft below its cleared level. Over the following 30 seconds,
level. Over the following 30 seconds, the controller tried to contact the aircraft again twice, but still without getting any response.
>> German Wings 18 Golf, come in please.
>> German Wings 18 Golf, this is Mar control. Come in, please.
control. Come in, please.
>> Instead, the speed in the cockpit was again increased, this time to 323 knots, which meant that the nose dropped once again.
Now, the captain was done in the toilet and likely very curious about what was going on in his cockpit. Like I said before, he would have noticed the descent for sure, as well as the various
changes in pitch aptitude. But having
been in this exact situation myself, he would have likely not been that worried at this stage. Surely all of this had a logical explanation. So he now entered
logical explanation. So he now entered the access code on the door keypad, which activated the 1 second buser inside of the cockpit.
But instead of immediately flicking the toggle switch to the unlock position, the first officer now instead switched it to lock, silencing the buser and disabling the keypad for the next 5
minutes, which would have also shown a glowing red diode to the captain waiting outside.
Now, this is where a cold feeling would have hit the captain for the first time.
Anyone knowing how this system works would have known what that red diode meant, but there could still be a chance that this was just some kind of simple mistake. And I have to think that he
mistake. And I have to think that he probably believed that.
Inside of the cockpit, the calls from the controller could still be heard as it was trying to reach the flight over and over again, but without getting any response. And as the plane descended
response. And as the plane descended through 25,500 ft, the controller also called on their previous frequency, hoping that they had somehow switched
back to there by mistake.
The speed selected on the FCU was now increased to 350 knots, the highest speed that was possible to let, which also corresponded to the aircraft's maximum allowed indicated air speed. The
nose therefore dropped even lower. And
at that kind of speed, the wind noise becomes quite noticeable, which is something that the captain outside would now have likely noticed. That and the fact that the foothills of the Alps were
now getting closer and closer outside of the windows.
At this point, a cabin chime could be heard, indicating that someone, likely the captain, wanted to reach the cockpit via the flight interphone since this was now the only way to send an audible
signal in there. And that was also accompanied by very loud knockings on the door.
But inside of the cockpit, the only thing that could be heard was the first officer's steady breathing and the air rushing by.
The autopilot remained engaged and the speed eventually stabilized at around 345 knots with Marseilles control now trying to reach the flight both on the international emergency frequency 1 to1
decimal 5 and their assigned frequency multiple times but still with no response. And around here the French air
response. And around here the French air defense was also made aware of this rogue aircraft and a fighter jet was being readed in order to take off and
intercept it. But at this point, it was
intercept it. But at this point, it was already too late. The southwestern part of the French Alps were now growing bigger and bigger in the windscreen, and
outside of the cockpit, the knocking had now changed over to violent banging and screaming. According to the sources, at
screaming. According to the sources, at times 0 937 and 13 seconds, the captain pleaded, "For the love of God, open this door," accompanied by other muffled
voices and screams in the background.
Just a few minutes later, the bangs on the doors were exchanged for violent blows instead when the captain apparently had found something hard that he could use to try and pry the door open, and he was now desperately trying
to use it in order to gain access to his cockpit. But the door did what it was
cockpit. But the door did what it was designed to do and resisted. Now, I
cannot think of a worse situation to be in than this one. both for the captain who was doing whatever he could to try and save this horrific situation and for all of the poor innocent passengers who by this time would have definitely
realized that something was seriously wrong. My only hope is that this
wrong. My only hope is that this knowledge was limited to the passengers in the front of the aircraft, but we will obviously never know that.
During the last 30 seconds of the flight, slight inputs on the first officer's side stick was recorded on the flight data recorder, but they were not large enough to disconnect the autopilot.
Another aircraft could now be heard on the radio trying to contact the flight, but without getting any response. And at
time 0940 and 41 seconds, the EGPWS, the ground proximity warning system, activated and started calling out >> terrain, terrain, pull up, pull up. And
that continued until the end of the recording. The very last thing that
recording. The very last thing that happened was the activation of a master caution warning. And then
caution warning. And then at time 0941 and 6 seconds, German wings flight 9525 slammed into a cliff face at
an altitude of around 5,000 ft, instantly killing everyone on board.
When the aircraft disappeared from radar in between the mountains, the French controllers likely understood what had happened, even if they didn't want to believe it at first. The scrambled
fighter jet was already on route, and it soon identified the smoldering pieces of the aircraft strewn all over the steep mountain side. This happened already at
mountain side. This happened already at time 1101, less than 20 minutes after the crash. And the investigation
the crash. And the investigation therefore started immediately with the recovery team soon working tirelessly sorting through the grueling rests of the aircraft in the ravines around the
impact site. And by a sheer coincidence,
impact site. And by a sheer coincidence, one of the workers stepped on the cockpit voice recorder among the millions of other parts in the debris field only a few hours after the
accident had occurred. The CVR was then rushed to the BEA headquarters in Paris where the memory module was found to be intact. So the outline of this horrible
intact. So the outline of this horrible story that I've just explained to you was basically made clear to the investigators from the very beginning.
Obviously, several recommendations were then added and the BEA made it very clear that all of those recommendations should be implemented altogether since
cherrypicking among them could actually give the opposite effect to the intended. These recommendations included
intended. These recommendations included better followup of pilots with a history of mental illness when it came time for renewal, specifically that a psychiatric evaluation might be needed. that the
airlines out there should include in their safety management systems ways to mitigate the socioeconomic risks related to a loss of license based on medical grounds. But maybe the most important
grounds. But maybe the most important one was a strong support for the implementation and use of strong peer support programs where pilots who struggle can have a safe haven to reach
out to and receive robust support without being stigmatized.
Now, I know that the feeling some of you will have after watching this video will be, "Well, I don't want any pilots with mental issues in my cockpit. Make sure
that that doesn't happen." But I need everyone to please understand that adding even more draconian measures than we already have in order to weed out people with lighter forms of depression
or similar will only cause these issues to stay hidden and further driven on the ground. it will not fix the root cause
ground. it will not fix the root cause and therefore will likely make the problem even worse.
I can say with almost 100% certainty that depressed pilots are flying out there right now and they are currently not feeling that they can trust the
system to help them. So we need as an industry to realize that even the initially most suitable pilots can face episodes of mental illness just like everyone else. And when that happens,
everyone else. And when that happens, they must feel like the industry have their backs. That they can step away
their backs. That they can step away from flying and get better and then have a realistic and supported way back again. But also, if something very grave
again. But also, if something very grave would be identified, like was clearly the case here, those symptoms needs to be caught early and the pilot needs to get financial support to mitigate the
impact of losing their livelihood like they do in parts of the nuclear industry, for example.
So in summary, getting pilots to accurately self-report is the only way for this problem to get any better. And
the current system is not yet 100% built to make this happen. So to improve this and to build confidence in a fair process is an absolutely crucial must in
order to keep tragedies like this one from ever happening again. And if you are feeling like you are struggling mentally, I will link to some helpful resources in the description. below.
Finally, to all of my pilot friends out there, please make full use of your company's peer support program or international ones like Project Wingman or Talk to a Peer if you feel like you
need it. They are there to help and from
need it. They are there to help and from what I hear, they are really great at what they do.
Now, this has been one of the toughest videos that I've ever had to make, and I hope that it gave you some understanding around something that at its core is almost impossible to comprehend. If you
did, and you want to support my team and I in our quest to make aviation safer for everyone, then please use this QR code or go to patreon.com/join/mentor
pilot and sign up. It really helps. My
name is Peter Hornfeld and you're watching Mentor Pilot. Have an
absolutely fantastic day and I'll see you next time. Bye-bye.
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