Aviation occurrence briefs

Flight crew incapacitation involving Diamond DA 40, 67 km W of Adelaide, SA, on 9 March 2019

Number:
AB-2019-010
Status: Completed
Investigation completed

Brief

Occurrence Briefs are concise reports that detail the facts surrounding a transport safety occurrence, as received in the initial notification and any follow-up enquiries. They provide an opportunity to share safety messages in the absence of an investigation.

What happened

On 9 March 2019, the pilot of a Diamond DA 40 was conducting a solo navigation flight from Port Augusta, South Australia (SA) to Parafield, SA. The pilot departed Port Augusta at about 0950 Central Daylight-saving Time (CDT).

About 40 minutes into the flight, the pilot began to feel a headache in his forehead and engaged the autopilot on a heading of 180⁰ and altitude 5,500 ft. Shortly after, the pilot became unconscious.

At about 1100 CDT, the aircraft infringed Class C airspace[1] and Air Traffic Control (ATC) attempted to contact the pilot numerous times unsuccessfully. The crew of a Diamond DA 42, which was operating in the area, offered their assistance to ATC in identifying and establishing contact with the aircraft. At about 1115 CDT, the crew made visual contact with the DA 40 and reported the pilot had regained consciousness. At this point, the aircraft was over water, 46 km south-south-west of Adelaide. Radio contact was subsequently established and ATC assisted the pilot in returning the aircraft to Parafield whilst under escort by the DA 42.

It is estimated that the pilot was unconscious for approximately 40 minutes.

Pilot comments

The pilot advised that the night prior to the flight he had suffered from a restless night of sleep and was recovering from a mild cold. On the day of the flight, the pilot did not consume any breakfast prior to departing from Parafield to Port Augusta. During the flight from Parafield to Port Augusta, the pilot only consumed a bottle of Gatorade, some water and a chocolate bar during the stopover in Port Augusta.

Safety action

As a result of this occurrence, the operator has advised the ATSB that they are taking the following safety actions:

  • Provide guidance that is more specific to students regarding sleep patterns and practical methods to ensure students are well rested.
  • Students will be required to include in their flight authorisation form their hours of sleep in the previous 24 and 48 hours, the time of when their last meal was consumed and the type of meal.
  • Conduct a safety briefing to re-emphasize the importance of observing company guidelines and responsibilities of the pilot in command, with more emphasis on fatigue management.

Safety message

This occurrence highlights the importance of flight crew assessing their ability to fly prior to flight. It is the flight crew’s responsibility to monitor their own health and wellbeing, to ensure that they are well rested and adequately nourished, especially during single pilot operations. Research conducted by the ATSB has found that 70 per cent of pilot incapacitation occurrences in general aviation had an effect on flight operations, in particular return to departure aerodrome or collision with terrain.

Further information about assessing your fitness to fly and pilot incapacitation can be found on the ATSB website, Are you fit to fly? and Pilot incapacitation occurrences 2010-2014.

About this report

Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.

 

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  1. Class C airspace: This is the controlled airspace surrounding major airports. Both IFR and VFR flights are permitted and must communicate with air traffic control. IFR aircraft are positively separated from both IFR and VFR aircraft. VFR aircraft are provided traffic information on other VFR aircraft.
General details
Date: 09 March 2019   Investigation status: Completed  
Time: 1030 CDT    
Location   (show map): 67 km west of Adelaide    
State: South Australia    
Release Date: 30 April 2019   Occurrence category: Serious Incident  
Report status: Final    

Aircraft details

Aircraft details
Aircraft manufacturer Diamond Aircraft Industries  
Aircraft model DA 40  
Type of operation Flying Training  
Sector Piston  
Damage to aircraft Nil  
Departure point Port Augusta, South Australia  
Destination Parafield, South Australia  
Last update 31 July 2019