What happened
On July 6, 2011, a BOEING 737-800, registration EI-DLW, was operating a scheduled international passenger flight from Pisa to Las Palmas de Gran Canaria. Approximately 30 minutes after takeoff, during the cruise phase, the copilot notified the captain of a headache. Shortly thereafter, the copilot began experiencing nausea and tremors before losing consciousness.
The captain immediately assumed control of the aircraft and requested the assistance of the purser. The purser entered the cockpit, secured the incapacitated copilot, and administered supplemental oxygen. The captain declared a medical emergency to Air Traffic Control (ATC) and requested a diversion to Girona Airport (LEGE).
While the copilot regained consciousness during the flight, he remained incapacitated in his seat. The captain managed the approach to Girona using autopilot until an altitude of 200 feet, at which point he transitioned to manual control. The aircraft landed at 14:06 UTC, where medical services and ambulances were waiting. The copilot was transported to a hospital, where tests confirmed the event was a vasovagal syncope and revealed no underlying chronic health issues.
The investigation
The CIAIAC examined the flight data, cockpit voice recorder (CVR), and flight data recorder (FDR) to reconstruct the sequence of events. The investigation reviewed the medical history of the copilot, the airline's operational manuals, and the emergency response protocols at Girona Airport.
Investigators analyzed the communication between the flight crew and ATC Marseille, Barcelona, and Girona Tower. The investigation also scrutinized the airline's training programs, specifically noting that while the crew had undergone periodic training, the simulator sessions primarily focused on the incapacitation of the captain rather than the copilot. Furthermore, the investigation looked into the activation of the airport's emergency plan and the distinction between a "medical emergency" and a "declared flight emergency."
Findings
- The sudden vasovagal syncope of the copilot was the primary cause of the incident, likely triggered by prolonged heat exposure during a walk to the airport on a hot day.
- The crew did not utilize the full scope of available resources, such as inquiring about medical personnel or qualified pilots among the passengers, as suggested by company procedures.
- The captain did not request the purser to assist with reading checklists during the approach, which increased the pilot's workload.
- There was a lack of clarity in the airline's documentation regarding the specific phraseology (such as MAYDAY or PAN PAN) to be used during crew incapacitation.
- The use of the term "medical emergency" by the pilot, rather than a formal declaration of an emergency, led ATC and airport ground services to treat the event as a "Local Medical Alert" rather than a "General Alarm," despite the known incapacitation of a flight crew member.
Safety action
- It is recommended that Ryanair include copilot incapacitation scenarios in its simulator training and proficiency programs.
- It is recommended that Ryanair revise its Operations Manual and Safety and Emergency Procedures to clarify emergency declaration protocols and the role of the purser during landing.
- It is recommended that AENA ensure ATC and airport coordination centers recognize crew incapacitation as a situation affecting flight safety, requiring the activation of full emergency response resources.