Andreas Lubitz’s journey to his final flight at the controls of Germanwings Flight 9525 exposed a series of failures and weaknesses at Lufthansa and throughout the industry and its regulators in dealing with mental illness among pilots.

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DUESSELDORF, Germany — When Andreas Lubitz sent an email in 2009 seeking reinstatement to Lufthansa’s flight-training program after a months-long absence, he appended what in retrospect was a clear warning about his fitness to fly passenger jetliners: an acknowledgment that he had suffered from severe depression.

Lufthansa put the German back through its standard applicant-screening process and medical tests. But it did not, from everything known about the case, pursue any plan to ensure that he was getting appropriate treatment. Nor did it impose special monitoring of his condition beyond that required for any pilot who had a flagged health problem. Instead, Lubitz made his way through the training program and became an Airbus A320 co-pilot for Lufthansa’s low-cost subsidiary, Germanwings.

After Lubitz, 27, flew himself and 149 other people into a French mountainside, Lufthansa’s chief executive said Lubitz had been “100 percent” fit to fly, showing how unaware the airline was of the extent of the pilot’s psychological troubles.

Lubitz’s journey to the moment he found himself alone at the controls of Germanwings Flight 9525 from Barcelona, Spain, to Duesseldorf on March 24 exposed a series of failures and weaknesses at Lufthansa and throughout the industry and its regulators in dealing with mental illness among pilots.

Information about Lubitz’s history remains sketchy, but there is evidence his psychological problems were well-established by the time Lufthansa was training him to fly. Just days after Lufthansa’s chief executive, Carsten Spohr, vouched for Lubitz’s flightworthiness, German prosecutors disclosed Lubitz had exhibited suicidal tendencies and been treated by psychotherapists over a long period before earning his pilot’s license.

“If I had known about his medical problems with depression before starting his flying career and during his primary training, I probably would not have accepted him,” said Reiner Kemmler, the former head of Lufthansa’s department of aviation psychology.

As recently as 2012, the International Civil Aviation Organization, an arm of the United Nations that serves as the umbrella organization for airline regulation, raised the lack of systemic screening for psychological problems as a weakness that needed to be addressed, particularly with regard to younger pilots.

The Montreal-based group’s 2012 Manual of Civil Aviation Medicine cited “an apparent mismatch” between the likelihood that mental rather than physical problems would afflict young pilots, “and the tools being used to detect them (the traditional medical examination).”

“Denial by the industry”

The culture of privacy in Germany created a bias against delving into Lubitz’s condition and effectively blinded the country’s airline regulator to the medical problems afflicting German pilots.

The German Federal Aviation Office, which issues pilot licenses, relies entirely on the country’s licensed flight doctors to determine pilots’ fitness to fly. But an audit last year by the European Aviation Safety Agency found that Germany’s strict data-protection rules mean that the information flight doctors submit to the regulator is not sufficiently detailed to allow officials to validate the doctors’ findings.

Other nations have taken stricter measures than Germany has when it comes to dealing with depression and other mental illnesses among flight crews.

Dr. Richard Soderberg, chief medical officer at the civil-aviation and maritime department of the Swedish Transport Agency, said that while depression would not permanently disqualify a pilot in Sweden, the pilot would be grounded during treatment. The agency would then require the pilot turn over all medical records pertaining to the depression and submit to psychiatric evaluation every six weeks or so, and the pilot would not be allowed to fly alone.

“The privacy of the pilot cannot be traded for aviation safety,” Soderberg said.

Though the highest-profile example of the pilot-suicide problem, Lubitz was far from an isolated case. In recent years, a series of commercial pilots appears to have crashed aircraft intentionally or been stopped by fellow crew members as they tried. In most cases, those pilots had been screened for psychological problems.

“There was almost a denial by the industry, and in particular among pilots, that we don’t do things like that,” said Robert Scott, a former British navy pilot and aviation consultant in Vancouver, B.C., who also heads a branch of the Canadian Mental Health Association. “It’s not part of our culture. It’s beyond the pale.

“Now we have so much evidence that we have grudgingly come to accept that, yes, it is a problem.”

In 1997, a SilkAir Boeing 737 crashed in Indonesia, killing all 104 people aboard. The pilot had recently been demoted. Investigators later learned he was also under financial and family strains. U.S. investigators concluded he had committed suicide. But Indonesian investigators ruled out that explanation.

Two years later, an EgyptAir Boeing 767 departing New York crashed into the Atlantic off Nantucket, Mass., and killed 217 people. The National Transportation Safety Board concluded the co-pilot purposely put the jetliner into a steep dive after uttering repeatedly, “I rely on God.” Under pressure from Egyptian officials, U.S. investigators did not deem the crash a suicide, but ruled out mechanical failures and blamed the co-pilot’s actions at the controls.

The lack of any substantive evidence of what happened to Malaysia Airlines Flight 370 last year has led investigators to consider the possibility the plane might be another example of one of the pilots’ deliberately downing the aircraft.

There also have been close calls. Most recently, in March 2012, a JetBlue flight to Las Vegas was diverted after the captain began talking incoherently about religion, 9/11 and Iraq, and said: “We need to take a leap of faith.”

An off-duty JetBlue pilot on board teamed up with the co-pilot to lock the captain out of the cockpit. Passengers helped subdue the troubled pilot, who was trying to re-enter the cockpit. He was later found not guilty of criminal charges by reason of insanity.

There is a common theme of denial in many cases of pilot suicide, as the responses of the Egyptians and the Indonesians demonstrate.

“We can no longer feel 100 percent confident in the person sitting beside us in the cockpit,” said Scott, the aviation consultant and pilot. “That is an awful feeling.”

Flight doctors are well aware of the risks.

“It remains astonishing how many pilots with mild or fading depressive disorders taking antidepressants flew without the knowledge of flight doctors — and still fly for us,” Dr. Uwe Stueben and Dr. Juergen Kriebel, who both worked for Lufthansa, wrote in the abstract of a paper published in 2011, while Lubitz was a trainee.

In 2009, the year Lubitz returned from his months-long absence from training, Stueben was Lufthansa’s director of medical services and would have been involved in evaluating Lubitz’s case, while Kriebel, also employed at Lufthansa’s aeromedical center at the time, normally performed psychiatric examinations on the young trainees.

Stueben declined to comment for this article. Reached by telephone, Kriebel said: “I won’t comment on the situation because the facts of the crash fall under my obligation of confidentiality.”

Privacy, deceit

European Union regulations that took effect in April 2013 require flight doctors to refer pilots with certain medical or psychological conditions — including depression — to national aviation authorities.

Because of his previous episode of depression there was a mark in Lubitz’s medical file that required flight doctors to examine him for any signs of a recurrence — and to refer the case to regulators only if they suspected that had happened. Lufthansa has declined to disclose the nature or intensity of those examinations.

Lubitz applied to join Lufthansa’s flight academy straight out of high school and in 2008 was among the roughly 5 percent of applicants accepted into the training program. But he broke off his training and for several months received psychiatric care.

When he was ready to return to the flight school the next year, he sent Lufthansa the email about his “episode of severe depression,” attaching medical documents, the company said. He received his commercial pilot’s license in 2012.

There appear to be additional delays in Lubitz’s training beyond the break of several months in 2009. He was accepted into the training program, which usually takes 1½ to 2 years, in 2008, but did not begin working for Germanwings until September 2013. Even with the 11 months that the company said he worked as a flight attendant, waiting for a pilot slot to open up, significant gaps in his career remain publicly unaccounted for. Lufthansa declined to provide a fuller accounting.

Before his final flight, Lubitz seems to have plotted his own demise and that of his passengers, investigators say. He researched methods of committing suicide, investigators say, and looked into cockpit-security procedures.

When he left for work March 24, his iPad browser, according to one investigator, still had tabs open about two recent airline disasters. They were the mysterious disappearance last year of Malaysia Airlines Flight 370 and the Mozambique Airlines flight in 2013 in which the captain was found to have intentionally crashed in Namibia, killing himself, five other crew members and all 27 passengers.

Although he had passed his standard medical exam by a flight doctor in August, he had more recent notes from specialists declaring him unfit to work that he never shared with his employer.

Investigators believe he visited dozens of different doctors, in part so none would recognize the true scope of his health problem, according to an official who spoke on the condition of anonymity because of German privacy laws. Prosecutors said Lubitz did not go to Lufthansa for help with his medical condition. That could have grounded him — and possibly cost him his job.

The final moments

The jetliner took off from Duesseldorf to Barcelona at 6:45 a.m. on March 24. The captain, Patrick Sondenheimer, flew to Spain but it was agreed his co-pilot would fly back.

The plane left Barcelona shortly after 10 a.m. Before long the plane was cruising at 38,000 feet, the pilots chatting, according to one investigator who has read a transcript of the flight’s cockpit audio recording.

The captain decided to go to the restroom at 10:30 a.m. Lubitz, alone in the cockpit, set the aircraft on a gradual descent. France’s Bureau of Investigations and Analyses said the readings from the flight’s data recorder showed he programmed the autopilot to fly the plane down to an altitude of 100 feet.

Sondenheimer pounded on the door with increasing desperation, demanding to be let in. Air traffic controllers called to say the plane’s altitude was too low. Automated systems repeated their commands for him to pull up. From outside the cockpit came screams from passengers. Amid this cacophony, Lubitz was silent. Only his steady breathing could be heard on the audio recording as he flew for the last time.