Aviation safety investigations & reports

Pilot incapacitation involving Cessna 208B, VH-DQP, near Brisbane Airport, Queensland, on 2 July 2020

Investigation number:
AO-2020-032
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final

Download Final report
[Download  PDF: 497KB]
 

What happened

On the afternoon of 2 July 2020, the pilot of a Cessna 208B aircraft, registered VH-DQP, was conducting a ferry flight from Cairns to Redcliffe, Queensland. After encountering unforecast icing conditions and poor visibility due to cloud, the pilot climbed from 10,000 ft to 11,000 ft. When the aircraft was about 53 km west-north-west of Sunshine Coast Airport, air traffic control attempted to contact the pilot regarding the descent into Redcliffe. No response was received from the pilot at that time, or for the next 40 minutes. During this time, air traffic control, with the assistance of pilots from nearby aircraft, made further attempts to contact the pilot of VH‑DQP.

When the aircraft was about 111 km south-south-east of the intended destination, the pilot woke and communications were re-established. The pilot was instructed by air traffic control to land at Gold Coast Airport. The pilot tracked to the Gold Coast and landed safely without further incident.

What the ATSB found

The ATSB found that the pilot was likely experiencing a level of fatigue due to inadequate sleep the night before and leading up to the incident. Further, operating at 11,000 ft with intermittent use of supplemental oxygen likely resulted in the pilot experiencing mild hypoxia. This likely exacerbated the pilot’s existing fatigue and contributed to the pilot falling asleep.

Safety message

The ATSB SafetyWatch highlights the broad safety concerns that come out of our investigation findings and from the occurrence data reported by industry. One of the priorities is Fatigue, which is a physical and psychological state typically caused by prolonged wakefulness and /or inadequate sleep. Most people generally underestimate their level of fatigue and tend to overestimate their abilities. The incident emphasises the importance of pilots monitoring their own health and wellbeing, to ensure that they are well-rested and adequately nourished, especially when conducting single pilot operations.

Further, it demonstrates that, although mild hypoxia is not known to impair complex cognition it has been found to increase fatigue and decrease vigour. Symptoms of hypoxia can begin very subtly at lower altitudes and can also begin to show below 10,000 ft for people who are smokers, unfit, or fighting off an illness.

Further information about assessing your fitness to fly and hypoxia can be found on the ATSB website and in the Flight Safety Australia article Do not go gentle: the harsh facts of hypoxia.

Download Final report
[Download  PDF: 497KB]
 
 
 

The investigation

General details
Date: 02 July 2020   Investigation status: Completed  
Time: 1644 EST   Investigation level: Short - click for an explanation of investigation levels  
Location   (show map): 56 km west-north-west of Sunshine Coast   Investigation phase: Final report: Dissemination  
State: Queensland   Occurrence type: Flight crew incapacitation  
Release date: 26 May 2021   Occurrence category: Serious Incident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Cessna Aircraft Company  
Aircraft model 208B  
Aircraft registration VH-DQP  
Serial number 208B2069  
Type of operation General Aviation  
Sector Turboprop  
Damage to aircraft Nil  
Departure point Cairns, Queensland  
Destination Redcliffe, Queensland  
Last update 26 May 2021