Incident Summary
On 21 July 2022, an Airbus A320-200, registration PK-GLW, operated by PT Citilink Indonesia, was conducting scheduled passenger flight CTV307 from Juanda International Airport, Surabaya, to Sultan Hasanuddin International Airport, Makassar. The flight crew consisted of a Pilot in Command (PIC) acting as Pilot Monitoring and a Second in Command (SIC) acting as Pilot Flying. Four flight attendants and 171 passengers were also on board.
Flight and Incapacitation
The aircraft departed Surabaya at 0615 LT in daylight conditions. About one minute after takeoff, the SIC observed the PIC in a rigid posture. The SIC attempted to check the PIC's consciousness but received no response. The SIC then informed a flight attendant of the incapacitation. The flight attendant made an announcement seeking medical professionals and qualified pilots among the passengers. A medical doctor responded and was brought to the cockpit, but no other qualified pilot was available.
Medical Response and Return
The doctor examined the PIC and found no pulse followed by no breathing. The doctor suspected a heart attack or stroke. At 0620 LT, the SIC declared a PAN PAN urgency to the terminal control area controller, requesting a return to Surabaya due to pilot incapacitation. The aircraft landed on Runway 10 at 0656 LT. The SIC vacated the runway and taxied to the parking stand to expedite medical care. After parking, the forward cabin door was opened, and airport medical personnel entered to assess the PIC. The PIC was then transported to a hospital, where he was pronounced deceased upon arrival; the time of death was unknown. Passengers disembarked normally.
Investigation Findings
The Komite Nasional Keselamatan Transportasi (KNKT) investigated the serious incident. The investigation concluded that the absence of a further and fuller review to clarify an anomaly found during the last resting electrocardiogram (ECG), the duration of the exercise ECG being less than nine minutes, and the lack of a heart computed tomography (CT) scan during the last medical examination resulted in a lost opportunity for a more comprehensive assessment of the PIC's cardiac condition. The report identified contributing factors related to pilot medical examination and certification processes, as well as the airline's pilot incapacitation procedures. Safety recommendations were issued to the operator, the aviation medical center, and the Directorate General of Civil Aviation.
Safety Actions
Following the incident, the Directorate General of Civil Aviation, Citilink Indonesia, and the Balai Kesehatan Penerbangan (Aviation Medical Center) took safety actions. Additionally, safety recommendations were made to enhance pilot medical assessments, improve incapacitation recognition and response, and review relevant procedures.