Aviation safety investigations & reports

Pilot incapacitation involving Piper PA-31, VH-TWU, near King Island, Tasmania, on 8 November 2018

Investigation number:
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

Download final report
[Download  PDF: 264KB]

What happened

On the morning of 8 November 2018, a Piper PA-31-350, registered VH-TWU, was being used for a freight flight from Devonport to King Island, Tasmania. During this flight, the pilot fell asleep and overflew their destination with the autopilot engaged. About 78 km past the intended destination of King Island Airport the pilot awoke and manoeuvred the aircraft back to King Island.

What the ATSB found

A fatigue analysis was conducted and determined that at the time of the occurrence, the pilot was very likely acutely fatigued to a level affecting performance predominately due to the lack of recent sleep and hours awake. Although there was opportunity, the pilot did not plan or obtain sleep prior to commencing the night shift.

After landing at King Island, the pilot continued with their shift flying to Moorabbin without obtaining additional rest.

Safety message

This occurrence highlights the importance of pilots assessing their fitness (a condition which permits a generally high level of physical and mental performance) to fly prior to commencing their shift and continuing to monitor their fitness to fly throughout the shift, specifically their level of fatigue. Pilots should modify their usual routines where necessary to prepare for a night shift to ensure they are adequately rested before thesy commence duty. Organisations should consider the risks of allowing a worker to continue operating in their role directly after a fatigue related incident without corrective management.

Information from the Civil Aviation Safety Authority (CASA) on fatigue management is available on their website.

The ATSB SafetyWatch information on Fatigue provides more resources and information.

Download final report
[Download  PDF: 264KB]

The occurrence

General details
Date: 08 November 2018   Investigation status: Completed  
Time: 0715 AEDT   Investigation level: Short - click for an explanation of investigation levels  
Location   (show map): near King Island   Investigation phase: Final report: Dissemination  
State: Tasmania   Occurrence type: Flight crew incapacitation  
Release date: 25 June 2019   Occurrence category: Serious Incident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Piper Aircraft Corp  
Aircraft model PA-31-350  
Aircraft registration VH-TWU  
Serial number 31-7552110  
Operator Vortex Air  
Type of operation Air Transport Low Capacity  
Sector Piston  
Damage to aircraft Nil  
Departure point Devonport, Tasmania  
Destination King Island, Tasmania  
Last update 25 June 2019