Malmo RJ1H near Stockholm on Feb 2nd 2012, captain incapacitated

Last Update: May 2, 2013 / 14:48:26 GMT/Zulu time

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Photo of Malmo Aviation SE-DSX, AVRO RJ-100 Avroliner — Malmo Aviation SE-DSX, AVRO RJ-100 Avroliner (Photo credit: Anna Zvereva / Flickr / License: CC by-sa)

Incident Facts

Date of incident
Feb 2, 2012

Classification
Report

Cause
Captain incapacitated

Airline
Malmo Aviation

Flight number
TF-121

Departure
Stockholm Bromma, Sweden

Destination
Malmo, Sweden

Aircraft Registration
SE-DSX

Aircraft Type
AVRO RJ-100 Avroliner

ICAO Type Designator
RJ1H

A Malmo Aviation Avro RJ-100, registration SE-DSX performing flight TF-121 from Stockholm Bromma to Malmo (Sweden) with 102 passengers and 5 crew, was climbing through 5000 feet out of Stockholm's Bromma Airport's runway 30 when the commander (48, ATPL, 5,909 hours total, 2,334 hours on type), pilot flying, started to not feel well suffering from nausea and dizziness. The first officer (33, CPL, 5,331 hours total, 2,245 hours on type), pilot monitoring, assumed the role of pilot flying. After some more consideration the crew decided to return to Bromma Airport, the climb was stopped at about 8500 feet, cabin crew and passengers were told of a minor technical problem. At about that time the first officer also needed to assume the roles of both pilot flying and monitoring (radio communication, working checklists), the captain only sporadically participated in the operation of the aircraft. No emergency was declared, ATC was not aware of the flight crew incapacitation, the first officer advised company dispatch about a medical emergency on board without notifying them it was the commander of the flight. The aircraft landed safely on Bromma's runway 30 about 16 minutes after departure, after landing the captain announced to passengers he had fallen ill. The commander left the aircraft first and was taken care of by waiting medical services.

Sweden's Statens Haverikommission (SHK) released their final report concluding:

The incident was caused by a temporary illness in one of the pilots.

The SHK reported that the captain had suffered from right hip and right leg pain when in a seated position in the cockpit several weeks before the occurrence but had not yet made contact with a doctor which was scheduled for his next leave following the occurrence. While the aircraft climbed out the captain felt the pain suddenly withdraw, his vision darkened and tunnel vision developed, severe dizziness and nausea developed followed by cold sweat. While the tunnel vision disppeared the captain felt still incapacitated with his cognitive ability impaired. The captain was admitted to hospital after landing, blood samples were taken according to standard procedures "Crew suspects cabin air contaminated by engine oil". At that time the captain was feeling well again. The captain was discharged from hospital the following day without any concrete diagnosis, all blood samples were without findings.

The SHK analysed that although they understand that the captain did not want to raise undue concern with the passengers due to his illness, there was no reason why cabin crew was not informed about the true reason of their return. Cabin crew could have better prepared for possible deviations from standard procedures in that case. The decision to return to Bromma to spend as little time airborne as possible on single pilot operation was correct and necessary.

The first officer adhered to most of the crew incapacitation measures, however did not declare emergency and did not notify ATC about the captain incapacitation. While this probably had no impact in this particular flight, such a mayday call may become critical to provide the aircraft with highest priority and alert ATC to provide whatever assistance might be helpful to reduce workload of the remaining pilot and coordinate response of services to get medical assistance available as quickly as possible. The SHK reported that following the occurrence the operator amended its flight crew operating manual requiring an emergency call in case of flight crew incapacitation.

The SHK analysed that the symptoms described by the captain generally follow known patterns of incapacitation caused by contamination of cabin air, especially by TCP. However, the levels of oil needed to leak through engine seals to introduce sufficient contamination of cabin air as well as the fact that the captain was the only person on board suffering symptoms make it very unlikely that TCP was causing the symptoms even when considering that every human shows different individual sensitivities to such contamination.

In order to establish medically whether a TCP contamination had taken place it would have been necessary to compare the blood samples taken after the occurrence with blood samples taken before the event without the individual feeling ill. However, the captain's normal levels had not been determined, therefore it was not possible to determine, whether the by products of TCP could have contributed to the captain's illness. The SHK stated: "The taking of specimens is thus not effective unless the specimens are analysed with the right method and unless baseline values for the staff have been taken for comparison."

The SHK concluded analysis: "The incapacitation of the commander that occurred after take-off cannot be considered to have constituted a serious incident from a flight safety perspective. The safety barrier constituted by dual pilots has covered the situation in an effective manner without resulting consequences."