Citilink A320 at Surabaya on Jul 21st 2022, captain incapacitated

Last Update: December 22, 2022 / 16:20:00 GMT/Zulu time

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Incident Facts

Date of incident
Jul 21, 2022

Classification
Incident

Cause
Captain incapacitated

Airline
Citilink Garuda Indonesia

Flight number
QG-307

Departure
Surabaya, Indonesia

Destination
Ujung Pandang, Indonesia

Aircraft Registration
PK-GLW

Aircraft Type
Airbus A320

ICAO Type Designator
A320

A Citilink Airbus A320-200, registration PK-GLW performing flight QG-307 from Surabaya to Ujung Pandang (Indonesia) with 171 passengers and 6 crew, was climbing out of Surabaya's runway 28 when the first officer stopped the climb at about 14000 feet reporting the captain was incapacitated and requested to return to Surabaya. The aircraft was vectored for a RNP approach to runway 28 but needed to go around, the first officer requested another approach to runway 10, performed an ILS approach to runway 10 and landed the aircraft safely about 40 minutes after departure. The captain was taken to a hospital, but subsequently was reported to have died.

The aircraft remained on the ground for about 8 hours, then departed again with a replacement crew.

Indonesia's KNKT released their preliminary report stating that the captain (48, ATPL) was pilot monitoring, the first officer (26, CPL) was pilot flying. The KNKT summarized the sequence of events:

Prior to the flight, both pilots conducted blood pressure and oxygen saturation tests and the result for both pilots were normal. During the flight preparation, the Pilot in Command (PIC) conducted a pre-flight briefing to all crewmember in the aircraft. There was no report of health problem of crewmembers or aircraft technical system abnormality.

At 2315 UTC (0615 LT), on daylight condition, the aircraft departed Surabaya and about two minutes after, the SIC saw the PIC was in stiff position, the SIC attempted to check the PIC consciousness and was no response.

The SIC informed to Flight Attendant 1 (FA1) who then informed other FA. A doctor onboard the flight examined the PIC and conducted medical treatment to the PIC.

The SIC contacted the air traffic controller and Citilink operation ground station informed that the PIC was incapacitated and requested assistance.

The SIC flying the aircraft by himself including read and performed the checklist. The aircraft landed safely and stopped on the runway. Considering that the PIC required immediate assistance, then the SIC decided to continue taxi to the parking stand.

After the aircraft stopped and the forward cabin door was opened, the medical personnel of the airport entered the aircraft to examine the PIC condition. The PIC then transported to a hospital. The PIC was found dead upon arrival at the hospital.

In the factual narrative the KNKT stated:

The PIC made initial contact with the TMA controller and was instructed to climb to Flight Level (FL) 230 (altitude of 23,000 feet), and to fly directing to Waypoint PEDSO. The PIC responded the instruction by requesting the TMA controller to repeat the name of the waypoint. The TMA controller then repeated the instruction to direct Waypoint PEDSO. The PIC readback and relayed the instruction to the SIC.

At 0616 LT, an alert appeared on the Electronic Centralized Aircraft Monitoring (ECAM) showed that the Air Pack 2 was still in OFF and the SIC selected the Air Pack 2 to ON.

About few seconds later, the SIC saw the PIC was in stiff position, the SIC attempted to check the PIC consciousness and was no response. The SIC then engaged the autopilot.

At 0617 LT, the SIC asked the Flight Attendant (FA) to come to the cockpit by using the interphone. The FA1 came to the cockpit and was advised by the SIC that the PIC incapacitated. The FA1 then informed the FA3 that the PIC was incapacitated and asked her to seek medical assistance among the passengers.

The FA1 went back to the cockpit brought an aromatherapy oil to stimulate the PIC as she was assumed that the PIC was fainted.

At 0619 LT, the SIC declared an urgency message PAN PAN to the Citilink Operation personnel using company radio communication channel. The SIC informed that the PIC was incapacitated and planned to return to Surabaya. The Citilink Operation personnel acknowledged the situation.

At 0620 LT, the SIC declared the urgency message PAN PAN to TMA controller and requested returning to Surabaya due to one pilot incapacitation. The TMA controller instructed the SIC to fly direct to Waypoint SADPU and descend to altitude of 3,500 feet.

A medical doctor who onboard as a passenger, responded the flight attendant and at 0621 LT, the doctor came to the cockpit accompanied by FA3. After examined the PIC, the doctor asked portable oxygen to the FA3.

At 0626 LT, the TMA controller asked the pilot whether requiring assistance on arrival and was responded by the SIC that they need 15 minutes holding.

The FA3 came to deliver portable oxygen bottle, along with FA2 who brought Emergency Medical Kit (EMK). At 0628 LT, the FA1 put on the oxygen mask to the PIC. About the same time, the TMA controller instructed the SIC to contact Surabaya Approach controller on frequency 123.2 MHz as the further approach control service would be provided by Approach (APP) controller.

The SIC made initial contact with APP controller and informed that the aircraft was holding on Waypoint SADPU. The APP controller responded by advising the SIC to report when ready for approach.

At 0630 LT, the APP controller instructed the SIC to turn left on heading 360° for traffic separation, and was acknowledged by the SIC. The APP controller then confirmed to the SIC whether any objection for another aircraft would be given a clearance to make landing approach prior to the CTV307. The SIC advised that he did not objection. The APP controller then instructed the SIC to return to Waypoint SADPU and maintain at altitude of 5,000 feet.

At 0632 LT, the Citilink Operation personnel asked the SIC whether need any assistance on arrival. The SIC requested an ambulance and ground support for electrical power and air conditioning as the Auxiliary Power Unit (APU) of the aircraft was unserviceable.

At 0634 LT, the FA3 made passenger announcement seeking a qualified Airbus A320 pilot on board the aircraft, however, there was no qualified pilot on board as passenger.

At 0635 LT, the SIC informed ready for approach to the APP controller and was approved to continue the landing approach to Runway 28 and to descend to altitude of 3,500 feet. The APP controller then canceled the clearance of another aircraft that was making a landing approach, with intention to give the CTV307 priority to land.

About 0637 LT, the doctor advised the FA1 and FA2 that the PIC breathing and pulse were no longer detected. The doctor also asked both FAs to lay down the PIC on the cockpit floor. After the PIC laid down on the cockpit floor, resuscitation was given to the PIC by the doctor and assisted by the two FAs.

At 0638 LT, the APP controller cleared the SIC to descend to altitude of 2,500 feet and to make Required Navigation Performance (RNP) approach to Runway 28.

At 0642 LT, when the aircraft was about 7 Nm to the runway, the APP controller instructed the pilot to contact the TWR controller and then was issued a clearance to land using Runway 28.

After hearing the landing gear was being extended, the FA1 went to cabin to conduct landing preparation and asked the FA3 to announce that the aircraft was about to land.

When the aircraft altitude was about 2,000 feet, the SIC decided to make a go around considering that the flight was un-stabilize and the doctor with the FA2 were still resuscitating the PIC. At 0645 LT, the SIC advised making a go around to the TWR controller and requested to make landing approach using Runway 10. The TWR controller then instructed the pilot to climb to altitude of 5,000 feet and fly to Waypoint LOTEK.

At 0649 LT, the SIC suggested the doctor and the FA2 to return the PIC to his seat as the aircraft was about to land. The FA2 asked the FA3 to assist returning the PIC on his seat.

At 0650 UTC, the SIC reported to the TWR controller that the aircraft was establishing localizer of Instrument Landing System (ILS) Runway 10 and was instructed to continue the landing approach. About one minute later, the SIC asked the FA2 to fasten the seatbelt and to lock the PIC shoulder harness. The FA3 and the doctor went back to the cabin, while FA2 remained in the cockpit and occupied the third pilot seat to make sure the PIC was well guarded.

Since the PIC had incapacitated, the SIC flying the aircraft by himself including read and performed the checklist.

At 0656 LT, the aircraft landed on Runway 10 with flap full down configuration and autobrake medium selection. The landing weight was estimated on overweight condition (64.7 tons). After landing, the SIC stopped for about a minute on the runway near Taxiway N5. The TWR controller confirmed the SIC whether if everything was fine and was affirmed.

Considering that the PIC required immediate assistance, then the SIC decided to vacate the runway via Taxiway N6 to the Parking Stand 6 of the Terminal 1. After the aircraft stopped and the forward cabin door was opened, the medical personnel of the airport entered the aircraft to examine the PIC condition. The PIC then transported to a hospital. The PIC was found death upon arrival at the hospital and the time of death was unknown.

Afterward, the passengers disembarked the aircraft. No injury reported in this occurrence. No damage to the aircraft nor to airport facility reported.