Features Safety
Sudden aircrew incapacitation

In January 2008 the copilot of a Heathrow-bound passenger flight had to be dragged from the cockpit and handcuffed after suffering an apparent mental breakdown in mid-air. According to the Guardian newspaper, “Passengers on the flight from Toronto to London said the copilot was restrained after yelling and ‘invoking God’ while at the controls of the Boeing 767 plane more than 30,000 feet above the Atlantic. The flight was forced to make an emergency diversion to Ireland’s Shannon Airport and the unnamed crew member was taken to a nearby psychiatric unit.”

The people most likely to notice a psychiatric issue in a crew member are either other crew members or immediate family and/or friends.

There has been significant press coverage about several sudden incapacitations among commercial aircrew recently, and this has raised the issue to a high profile, certainly among non-pilots and the media.

A month after the Heathrow-bound 767 incident, a photo was published (tastelessly in my opinion) of a relatively young co-pilot who died enroute on a flight within Europe. The photo showed the pilot collapsed in the co-pilot chair. I am not sure how the press managed to get such a photo; I would have hoped that the airline would have had the time to at least cover up the deceased, but this did not occur. I have no personal knowledge about these cases other than what I read in the newspapers, but I am comfortable commenting on this issue in general. These stories certainly sell newspapers, but the actual chance of a sudden incapacitating event among aircrew is extremely rare. If these events had happened to these individuals on the drive to the airport the stories wouldn’t have seen the light of day, as they wouldn’t be deemed newsworthy. For the travelling public, the odds of the two pilots (irrespective of their age) actually becoming incapacitated for medical reasons at the same time is almost zero (pretty well the same odds as winning a lottery or being hit by lightning!). In fact, an article published in the journal of the Aerospace Medical Association noted that between 1972 and 1988 the world’s airlines flew more than 190 million hours without realizing a single accident involving pilot incapacitation. The latest estimated risk of cardiac incapacitation occurring at a critical point in a flight is less than one event among more than 20 million flight hours, with the risk of an accident occurring once every 400 years. The risk of other forms of incapacitation would be even lower.

When air crew undergo their favourite aviation medical, in any country, the medical examiner is particularly interested in anything that may indicate a risk for sudden incapacitation whether they are private or commercial pilots. The most common reasons for sudden incapacitation are cardiac – heart attack or stroke – metabolic (e.g., diabetes), malignancy (cancer that has spread to areas such as the brain) and psychiatric (as in the case described above). This is why there is a heavy focus, certainly in Canada, on cardiac and metabolic areas of the examination. To be honest, psychiatric issues are difficult to pick up in a brief medical encounter unless the individual is overtly psychotic, and it is usually your staff that notices unusual behaviour first. Most folks, even if undergoing a mild to moderate psychiatric episode, can bluff their way through the half-hour aviation medical. In fact, the folks most likely to notice a psychiatric issue in a crew member are either other crew members or immediate family and/or friends. The point here is that we all get to know people very well, especially if we have flown with them for years, and if you notice a significant change in their behaviour it behooves you to bring it to the attention of the safety people at your organization. It may seem awkward to be “turning someone in,” but in the long run we will all be safer and that individual could receive appropriate treatment and be returned to flying duties – and it could prevent any other exciting media stories.

As aviation medical examiners, we are not as concerned about your athlete’s foot since this isn’t likely to bring down an airliner, but we do focus our examination in areas that may make someone suddenly unable to function on the flight deck. Of course, I am not advocating “turning in” your boss because he gave you a crappy flight schedule and telling the safety organization that you are concerned because you feel your boss is psychotic. There are other means of dealing with these issues but they are not the subject of aviation medicine! Most airlines have some form of standard operating procedure (SOP) in the event of the sudden incapacitation of a crew member. The general principles that are to be followed are as follows: 1) The in-charge flight attendant will pull out and follow the medical emergency checklist; 2) The remaining pilot will contact flight dispatch and the contract Emergency Medical Company via radio and/or datalink; 3) A diversion will be planned if needed between dispatch, the Emergency Medical Company and the remaining pilot based on services needed and current situation (fuel, weather, etc.); 4) The incapacitated crew member will be cared for with the onboard medical kit and expertise; and 5) The remaining pilot will conduct the remainder of the flight as a single pilot.

Scenarios such as these are covered in both pilot and flight attendant training. Pilot simulator training includes scenarios such as incapacitation of the flying pilot in critical phases of flight (takeoff, approach and landing) to emphasize the need for following the SOPs, the use of the challenge-response concept, and to remind pilots that the pilot not flying should remain ready at all times to take the controls. The flying public should feel very comfortable that while an aircrew incapacitation can seem dramatic, the risk to safety is extremely low. These types of stories are more interesting to media organizations as they can be somewhat sensational, but have no real concern from a general flying safety perspective. 

Dr. Sardana is a pilot, a Civil Aviation Medicine Examiner (CAME), coroner and president of Aviation Medicine International (AMI) Inc. (www.aviationmedintl.com ). Comments on this article or future topic suggestions gladly appreciated at t.sardana@aviationmedintl.com .