Etihad A320 at Abu Dhabi on Nov 17th 2012, captain incapacitated

Last Update: September 21, 2015 / 13:54:08 GMT/Zulu time

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Incident Facts

Date of incident
Nov 17, 2012

Classification
Incident

Flight number
EY-308

Aircraft Registration
A6-EII

Aircraft Type
Airbus A320

ICAO Type Designator
A320

An Etihad Airbus A320-200, registration A6-EII performing flight EY-308 (dep Nov 16th) from Kuwait City (Kuwait) to Abu Dhabi (United Arab Emirates) with 70 passengers and 6 crew, was on a left downwind at 2500 feet on approach to Abu Dhabi's runway 31L when the first officer declared Mayday reporting the captain had become unconscious. The aircraft turned base and instead of turning left onto finals used a right hand turn of 270 degrees to intercept the localizer and continued for a safe landing on runway 31L about 13 minutes after the first officer declared emergency. The aircraft stopped on the runway, a medical team boarded the aircraft and treated the captain, who regained consciousness. The captain was taken to a hospital.

The BEA reported the aircraft was towed to the gate and reached the gate about 50 minutes after landing.

In Feb 2013 United Arab Emirates' Civil Aviation authority (GCAA) released a preliminary report stating that the captain was pilot flying while the aircraft was configured for approach and landing. During the approach, while descending towards the base leg, the captain became incoherent, 2 minutes later unresponsive and incapacitated, the first officer assumed control of the aircraft and informed ATC about the captain being incapacitated. The first officer landed the aircraft safely 13 minutes after first indications of the captain becoming incoherent and stopped the aircraft on the runway in compliance with the operator's policies. Paramedics reached the aircraft about 30 minutes after landing and boarded the aircraft to provide assistance to the captain, who had partially regained consciousness and was responding again. The aircraft was towed to the terminal, the captain then disembarked before all other occupants and was taken to a hospital.

On Sep 21st 2015 the GCAA released their final report concluding the causes of the incident were:

The Air Accident Investigation Sector determines that the cause of the captain’s incapacitation was the embolic event (stroke) that resulted in loss of consciousness.

The Investigation identifies the following contributing factors to the Incident:

- The captain suffers from antiphospholipid syndrome disease which led to the embolic/stroke event.

- No additional information on the captain’s medical history, except his hypertension, was made available to the medical examiner, such that no further medical treatment was prescribed to mitigate the possibility of an embolic event.

- The regulatory requirements current at the time of the incident did not enable the medical check to discover a specific syndrome or disease, and subsequently to reduce the possibility of a pilot incapacitation event by taking the necessary medication or therapy.

The GCAA reported that after the captain regained consciousness he was reacting and speaking normally, he thought he had fallen asleep and was puzzled that nobody had woken him up.

The GCAA reported that computer tomography and magnetic resonance imaging revealed: "The result of the scans revealed that the left cerebellum was intact, and the left occipital lobe infracted. Further tests including MRI angiogram and MRI angiography were performed. The result of the tests showed small infracts on cerebellum, and that the left occipital lobe was clear from occlusions."

The GCAA continued: "Two years before the Incident, the captain was diagnosed with hypertension. Accordingly, hypertension medication was prescribed for him. He declared his medical history of hypertension, and that he had been prescribed medication to control the condition. He provided this information during his license renewal application in July 2012. One year after the Incident, the captain had suffered no further episode, or loss of consciousness, or seizers. The continuous monitoring of blood clotting by using INR indicated that the captain’s condition was stable. The thorough medical investigation concluded that the captain was diagnosed with antiphospholipid syndrome (see Paragraph 1.18.4 for the details of the syndrome), which caused an embolic24 event (stroke) that caused him to lose consciousness."

The GCAA analysed:

During approach to Abu Dhabi International Airport, and while the Aircraft was maintaining 2,400 feet altitude and was approximately 9.5 nautical miles south east of the Airport, the captain said something to the co-pilot in an unusual tone of voice compared to his previous conversation. Within approximately one and a half minutes, the captain was attempting to verbalize unsuccessfully. This was associated with difficulty in breathing and incoherent verbal communication. The co-pilot noticed that the captain had suddenly become unconscious. Subsequently, the co-pilot took over the controls.

Approximately seven seconds after the captain’s last attempt to communicate, autopilot 1 was disengaged by the co-pilot, at this time the travel of the captain’s right rudder pedal reached approximately 13 degrees, and the Aircraft started to sideslip. The co-pilot disengaged autopilot 1 when he decided to take over control after realizing that the Aircraft was side-slipping. However, after the autopilot disengagement, the captain’s right pedal was still being subject to pressure continuously while it maintained a position of 14±1 degrees for another 18 seconds.

Autopilot 2 was engaged by the co-pilot in order to reduce the workload, but after seven seconds, the co-pilot disengaged it due to, most probably, noticing the continuous input of the captain’s right rudder pedal, which put the Aircraft into a 10 degree sideslip, and to lateral acceleration that reached approximately 0.26 g.

After the 18 second period of constant pressure on the right rudder pedal, the rudder input started to decrease and the pedal returned to the neutral position within 11 seconds. During the 29 seconds from the captain's full coma until the pedals returned to the neutral position, the co-pilot was making continuous attempts to recover the Aircraft to straight and level flight manually.

The duration of the continuous captain’s right rudder pedal input was approximately 37 seconds. This long and excessive rudder input was, most probably, due to muscle spasms resulting from the captain’s incapacitation.

Approximately four seconds after the rudder pedal had returned to the neutral position, the co-pilot re-engaged autopilot 1 in order to reduce his workload. However, 10 seconds after the engagement of autopilot 1, it disengaged automatically when the bank angle reached approximately 21 degrees. After 14 seconds the co-pilot re-engaged autopilot 1. Thereafter, autopilot 2 was also engaged to enable CAT 3 DUAL. Both autopilots remained engaged until 850 ft above ground level and then were disengaged by the co-pilot before the Aircraft landed.

There were some instructions from the Controller that could not be followed and performed by the co-pilot due to the condition and workload in the cockpit after the captain’s incapacitation.

The co-pilot required time to manage the situation. He discontinued the approach and requested permission to perform an orbit in order to acquire more time to ensure that the cockpit was prepared for landing. The co-pilot was able to manage with the assistance of the CM who was present in the cockpit taking care of the incapacitated captain. The co-pilot requested one of the cabin crew to ask, through the PA, if there was a doctor onboard, and he was also in continuous communication with the Approach Controller. The co-pilot landed the Aircraft uneventfully.

The Investigation believes that the co-pilot managed the cockpit efficiently after the captain's incapacitation. Although he intended to carry out the landing as soon as possible, he did not put himself under stress to perform a hasty approach. The co-pilot's actions were in accordance with the Operator’s Operations Manual, Part A, for pilot incapacitation and reflected good airmanship.

Although some instructions given by the Approach Controller could not be followed exactly, the Controller managed the requests from the Aircraft for the orbit and the landing, and controlled the traffic safely.

The CM assisted in managing the cockpit by restraining the captain's body in order to prevent any inadvertent inputs to the flight controls. The CM required assistance from another cabin crew member to ensure that the captain was supplied with oxygen by fixing the oxygen mask in place, as required.

The cabin crew members assisted the co-pilot and reacted as per the Operator’s Operations Manual, Part A, and Safety and Emergency Manual.

The Investigation believes that crew resource management (CRM) was practiced well in taking appropriate actions at proper times without putting the flight into a situation of increased risk.
Incident Facts

Date of incident
Nov 17, 2012

Classification
Incident

Flight number
EY-308

Aircraft Registration
A6-EII

Aircraft Type
Airbus A320

ICAO Type Designator
A320

This article is published under license from Avherald.com. © of text by Avherald.com.
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