What happened
On 21 July 2022, an Airbus A3/200, registration PK-GLW, operated by PT Citilink Indonesia, departed Juanda International Airport in Surabaya for Makassar. The flight, number CTV307, was carrying 171 passengers and a crew of six. Shortly after takeoff, while the aircraft was climbing through 2,400 feet, the Second in Command (SIC) noticed the Pilot in Command (PIC) had become unresponsive and was in a rigid physical state.
Upon realizing the pilot had incapacitated, the SIC notified the flight attendants, who then requested medical assistance from the passengers. A medical professional on board examined the PIC and found the pilot was pulseless and not breathing, suspecting a heart attack or stroke. The SIC declared an urgency message (PAN PAN) and requested an immediate return to Surabaya. The aircraft landed safely on Runway 10, and the pilot was transported to a hospital, where he was later pronounced deceased.
The investigation
The investigation by the KNKT focused on the medical fitness of the crew and the adequacy of the medical examination processes. Investigators examined the pilot's recent medical history, including an exercise electrocardiogram (ECG) and a resting ECG. The inquiry also reviewed the airline's training procedures for handling crew incapacitation and the communication protocols between medical professionals and nursing staff regarding diagnostic instructions.
Findings
- The investigation identified that the pilot's recent exercise ECG was incomplete, as the duration was less than the required nine minutes, which prevented a thorough cardiovascular assessment.
- A resting ECG performed months prior had shown an anomaly indicating inferior ischemia, but this was not further investigated because a subsequent exercise ECG appeared normal.
- A missed opportunity to perform a heart CT scan occurred because a verbal instruction from a cardiologist was not properly recorded or acted upon by medical staff.
- Training discrepancies were noted, including the use of outdated manuals for pilot incapacitation drills and a lack of practical training for flight attendants in using quick-donning oxygen masks.
- The airline lacked a specific procedure for managing situations where multiple medical professionals are present on board during an emergency.
Safety action
The KNKT issued several recommendations to the Directorate General of Civil Aviation (DGCA), the Aviation Medical Center, and Citilink Indonesia. These include improving the monitoring of crew members at risk of medical degradation, ensuring all ECG anomalies are followed up with comprehensive reviews, and updating training materials to ensure flight attendants can effectively administer oxygen during emergencies.