Description

On 21 February 2019, the Captain of an Airbus A350-900 (B-LRR) being operated by Cathay Pacific Airlines on a scheduled international passenger flight from Perth to Hong Kong as CPA170 became seriously unwell about 90 minutes from destination in the cruise but remained conscious. The First Officer took full control, a PAN was subsequently declared and the flight was completed as planned with assistance to the First Officer provided by a senior member of the cabin crew whilst a doctor on board provided appropriate medication and monitored the Captain’s condition. On arrival at destination, the Captain was conveyed to hospital. 

Investigation

A Serious Incident Investigation was opened by the Hong Kong Air Accident Investigation Authority (AAIA) in accordance with the prevailing Annex 13 guidance. 

The 59 year-old Captain had a total of 20,188 hours flying experience of which 94 hours were on type, all completed within the previous 90 days. The 46 year-old First Officer, who was acting as PF for the sector had a total of 7,607 hours flying experience of which 243 hours were on type with 147 of those hours flown in the previous 90 days. He held an appropriately endorsed ATPL.  

What Happened

The flight was an Extended Diversion Time Operations (EDTO) overnight sector with a two pilot flight crew. It was decided that the Captain would act as PM for the sector and the First Officer would act as PF. After completing the external pre departure check of the aircraft, the Captain had felt out of breath but quickly recovered. After about an hour in the air, the Captain again felt shortness of breath and used his oxygen mask to breathe 100% oxygen for 10 to 20 seconds. He initially felt better but “later put on the oxygen mask again”. Both pilots took periods of controlled rest in their seats as the flight progressed but as the flight passed west of the Philippines, the Captain “started to feel worse again (and) experienced difficulty in breathing, loss of visual acuity, dizziness, headache and chest pain”. He told the First Officer that he was “not feeling good and getting worse” and declared himself incapacitated. 

The First Officer called the Inflight Service Manager (ISM) to the flight deck and when she arrived, the Captain was “well enough to tell her his condition”. He confirmed incapacitation and handed over command to the First Officer. He remained in his seat but his seat harness restraints were secured and locked and his seat was moved to the fully aft position to preclude any possible interference with operation of the aircraft. 

The Captain remained conscious and was able to communicate adequately with the First Officer. The latter contacted the company Aviation Medical Office (AMO) via SATCOM and the former initially advised that the Captain should use oxygen as required and “have sugary drinks”. A medical doctor was identified from amongst the passengers and brought to the flight deck to assist. This doctor then occupied a supernumerary crew seat on the flight deck for the remainder of the flight. After communication between this doctor and the company AMO, the Captain was given several different medicines and “felt better”. He remained conscious and according to the First Officer, he had remained able to “speak about 60 to 70%”.   

The prevailing weather conditions were good and after discussion with the Captain, the First Officer decided to continue to Hong Kong rather than divert as he considered that landing there would involve a lower risk than the complications of a diversion. Once the flight had entered the Hong Kong FIR, the First Officer declared a PAN and requested an early descent in order to decrease the cabin altitude and thereby help the Captain to breathe more easily. ATC provided this and a shortened track to position for a landing at Hong Kong and from the top of descent onwards, the Senior Purser was assigned to assist the First Officer in the flight deck in accordance with the company QRH procedure for pilot incapacitation. 

The flight was completed without further problems and landed on runway 07R at Hong Kong approximately 1¼ hours after the First Officer had taken over. The AP was kept engaged until on final approach and a manual landing with the A/THR engaged was then performed followed by a normal taxi in. The Captain’s transfer to hospital and normal passenger disembarkation then followed. It was found that the Captain had no medical history relevant to his incapacitation and confirmed that his ATPL Medical certification was as required. 

The key Findings of the Investigation in respect of the response to the Captain’s unavailability were, in summary, as follows:

• The prevailing weather conditions were benign and were not a factor. 
• The Captain had sufficient rest before beginning his duty. 
• The aircraft operator had procedures, policy, guidance, and training covering pilot incapacitation for both flight crew and cabin crew.  
• The Captain’s incapacitation was self-evident and he advised the First Officer in a timely manner which allowed the First Officer and the cabin crew to take appropriate actions promptly. 
• The First Officer made optimal use of the autopilot system to control the aircraft.  
• The First Officer’s assessment of the contingency options and the decision to continue to the intended destination rather than divert to a nearer but less familiar large airport (Manila) was appropriate.  
• The First Officer used the electronic checklists as per the SOP with the Senior Purser available to read out the printed checklist had that been required. 
• The best use of the assistance and resources from ATC, cabin crew and aircraft automation reduced the complexity and workload of the situation for the First Officer. 
• The flight crew and cabin crew complied fully with the operational aspects of company procedures, policy, and guidance during the descent, approach, and landing. 

The Cause of the event was formally documented as “the Captain experienced difficulty in breathing, loss of visual acuity, dizziness, headache and chest pain and the situation continued to deteriorate”.

Event Classification 

At the time the event occurred, Attachment ‘C’ of ICAO Annex 13 Aircraft Accident and Incident Investigation was current in its Eleventh Edition and “flight crew incapacitation in flight” was listed as a typical example of a Serious Incident. Whilst the Investigation was in progress, the Twelfth Edition of the Annex was published in July 2020 with amplified guidance on “flight crew incapacitation in flight” for multi crew operations which it defined as a situation where its occurrence led to “flight safety being compromised because of a significant increase in workload for the remaining crew”. The revised Attachment ‘C’ guidance in the new edition of the Annex also introduced a generic “event risk-based analysis” to aid the process of identifying an event as a Serious Incident which proposed the following evaluation: 

• consider whether there is a credible scenario by which this incident could have escalated to an accident and
• assess the remaining defences between the incident and the potential accident as: 
  • effective, if several defences remained and needed to coincidently fail; or
  • limited, if few or no defences remained, or when an accident was only avoided due to providence. 

Based on this new guidance, the Investigation determined that on the basis of all the available evidence, the event should be reclassified as an Incident rather than a Serious Incident. 

The Final Report of the Investigation was completed in May 2023 and released online in August 2023. It was noted that in view of the findings of the Investigation on the crew response to the operation of the flight and the operator’s SOP for and training in crew incapacitation, no Safety Recommendations were appropriate.

Related Articles

• Pilot Incapacitation
• Flight Crew In-Seat Rest
• Standard Operating Procedures (SOPs)
• Risk Assessment
• Crew Incapacitation: Guidance for Controllers