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B738, en-route, south east of Marseilles France, 2011

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Summary
On 6 July 2011 the First Officer of a Ryanair Boeing 737-800 was suddenly incapacitated during a passenger flight from Pisa to Las Palmas. The Captain declared a ‘medical emergency’ and identified the First Officer as the affected person before diverting uneventfully to Girona. The subsequent investigation focused particularly on the way the event was perceived as a specifically medical emergency rather than also being an operational emergency as well as on the operator procedures for the situation encountered.
Event Details
When July 2011
Actual or Potential
Event Type
Human Factors, Loss of Control
Day/Night Day
Flight Conditions VMC
Flight Details
Aircraft BOEING 737-800
Operator Ryanair
Domicile Ireland
Type of Flight Public Transport (Passenger)
Origin Pisa International Airport
Intended Destination Gran Canaria
Actual Destination Girona-Costa Brava Airport
Take off Commenced Yes
Flight Airborne Yes
Flight Completed Yes
Flight Phase Cruise
ENR
Location En-Route
Origin Pisa International Airport
Destination Gran Canaria
Location
Approx. Approx 100nm SE of Marseilles
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General
Tag(s) Inadequate Aircraft Operator Procedures
HF
Tag(s) Flight Crew Incapacitation,
Procedural non compliance
LOC
Tag(s) Flight Crew Incapacitation
Outcome
Damage or injury No
Causal Factor Group(s)
Group(s) Aircraft Operation
Safety Recommendation(s)
Group(s) Aircraft Operation,
Air Traffic Management
Investigation Type
Type Independent

Description

On 6 July 2011 a Boeing 737-800 being operated by Ryanair on a scheduled passenger service from Pisa to Las Palmas in day Visual Meteorological Conditions (VMC) declared a ‘medical emergency’ when in the cruise south of Marseilles in day VMC because the First Officer had suddenly become incapacitated. An uneventful en route diversion to Girona followed and the First Officer was hospitalised.

Investigation

An Investigation was carried out by the CIAAIC on the basis that the issues raised by the occurrence were particularly evident once the diversion to Girona was under way.

It was established that about half an hour after take off, having been without any abnormal symptoms until then, the First Officer, who had been designated PF for the flight, advised the Captain that he was “feeling ill and had a headache". The Captain took over as PF and almost immediately, the First Officer began to feel nauseous and shake as well as failing to respond to the Captain’s questions and he eventually appeared to faint. The Senior Cabin Crew Member was called and secured the First Officer and administered oxygen.

A medical emergency due to incapacitation of the First Officer was declared to ATC (Marseilles ACC) but without use of either ‘MAYDAY’ or ‘PAN’ terminology. The subsequent diversion was nominated by the Captain and the ATC units involved rendered the usual assistance.

Once the initial Cabin Crew assistance was complete, the Captain indicated that he did not need assistance in operating the aircraft, although this was suggested in the operator’s procedures for pilot incapacitation. The First Officer took no further part in the operation of the aircraft. No inquiries as to the possible presence on board the aircraft of either medically trained personnel or qualified pilots were made.

Flight Data Recorder (FDR) data confirmed that the remainder of the flight had proceeded expeditiously and in accordance with standard operating procedures. The AP was left engaged until 200 feet aal on the approach which was stabilised throughout. Immediate medical attention had been requested for the First Officer on arrival at Girona and medical personnel were standing by ready to assist and transfer the First Officer to hospital.

The medical staff at the hospital where the First Officer was taken, noting that he had apparently experienced a partial or complete loss of consciousness accompanied by a loss of self-awareness and of his surroundings, indicated that, since the temporary loss of consciousness had been accompanied by a spontaneous recovery, he had most probably experienced a fainting fit or 'vasovagal syncope’.

It was noted that this syncope can occur in perfectly healthy people for various reasons including prolonged heat exposure. Since it was found that the First Officer had walked to Pisa airport in high temperature sunny conditions immediately prior to reporting for duty, it was considered that this triggered the syncope. An analysis of the medical history and subsequent tests indicated that the incapacitation “had not been due to a latent, and therefore foreseeable, medical problem”.

Although there had been no question that the response by ATC and the diversion airport had been consistent with the declaration of a ‘medical emergency’, the Investigation considered that the use of that phrase, despite in this case being allied with the fact that the person involved was one of the pilots, had nevertheless been, as a result, perceived as a situation that did not directly involve flight safety. For example, the need for ATC to proactively ease the task of navigating the aircraft or for the receiving airport to place their Rescue and Fire Fighting Services on local standby had not been foreseen. It was considered that had the declaration of either ‘PAN’ or ‘MAYDAY’ status been used as the primary notification rather than the sole use of the description ‘medical emergency’, the response might have more effectively addressed the fact that “independently of the risk to the health of the affected crew member, the incapacitation of a member of the flight crew on an aircraft certified for two pilots must be regarded as an emergency situation that threatens safety margins”.

Ryanair procedures and training for crew member incapacitation were reviewed against the actual response in the investigated case. It was found that whilst they were quite considerable, there remained a degree of vagueness in some respects, including a certain lack of clarity on the boundary between the discretion afforded to an aircraft commander and a requirement for him to comply with specific directions. In some instances, relevant procedures were “regarded as confusing”.

The Cause of the incident was formally given as “the sudden incapacitation of the First Officer which was medically classified as a syncope, probably caused by prolonged heat exposure. There were no indications in either the co-pilot’s medical history or in follow-up tests to suggest that the syncope could have been anticipated”.

Three Safety Recommendations were made as a result of the Investigation as follows:

  • that Ryanair include the incapacitation of the co-pilot, in addition to that of the pilot, as part of its simulator training and proficiency programs. [REC 16/12]
  • that Ryanair revise its Operations Manual (OM), its Safety and Emergency Procedures (SEP) and its simulator instructor’s guide as concerns the incapacitation of a flight crew member. Specifically, the text on the emergency declaration to be used in the event of an incapacitation and on the purser’s role in reading the checklists prior to landing should be improved. [REC 17/12]
  • that AENA ensure that personnel at both ATC stations and at airport coordination centres be made aware that the incapacitation of a flight crew member is a situation that affects the safety of a flight and that (it) must be treated as a declared in-flight emergency, in particular for the purposes of activating the Emergency Plan at the airport where the aircraft will be landing. [REC 18/12]

The IN-021/2011 Final Report of the Investigation was approved on 28 June 2012 and subsequently made available in English translation.

Further Reading