Aviation safety investigations & reports

Partial pilot incapacitation involving Piper PA-28, VH-TBB, 19 km south-east of Moree, New South Wales, on 23 September 2020

Investigation number:
AO-2020-055
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final

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What happened

On 23 September 2020, the pilot of a Piper PA-28 aircraft, registered VH-TBB, was conducting a ferry flight from Moree to Scone, New South Wales. Shortly after take-off, the pilot began to feel unwell with a warm feeling in their chest, dizziness, breathlessness, some confusion and disorientation. The pilot then observed a localised discolouration on the disposable carbon monoxide (CO) chemical spot detector. As the pilot looked closer at the detector, they noticed the spot rapidly getting darker. The pilot immediately returned to the airport, reduced engine power and opened all the fresh air vents and the side window. The aircraft landed safely at Moree and the pilot was subsequently taken to hospital for medical examination.

What the ATSB found

The ATSB found that the positive indications on two separate disposable CO chemical spot detectors, both during the flight and prior to the post-incident inspection, indicated that the pilot was likely exposed to elevated levels of CO in the aircraft cabin. Despite the pilot’s carboxyhaemoglobin level being mildly elevated, it was likely that their physical symptoms and cognitive effects were associated with CO poisoning.

Safety message

Carbon monoxide is a colourless and odourless gas, and its presence may not be detected until the development of physical symptoms and cognitive effects. Therefore, operators and owners of piston-engine aircraft are strongly encouraged to install a CO detector with an active warning to alert pilots to the presence of elevated levels of CO in the cabin. Should any smell or sensation of illness develop, pilots should check their CO detector, ensure cabin heat has been turned off, open all fresh air vents and windows, make prompt decisions to land as soon as possible, and use all available resources for assistance. Further information on CO poisoning and detectors can be found at the following:

Are you protected from carbon monoxide poisoning?

Carbon Monoxide: A Deadly Menace

Detection and Prevention of Carbon Monoxide Exposure in General Aviation Aircraft

Download Final report
[Download  PDF: 376KB]
 
 
Alternate: [Download  DOCX: 874KB]
 

The investigation

General details
Date: 23 September 2020   Investigation status: Completed  
Time: 14:18 EST   Investigation level: Short - click for an explanation of investigation levels  
Location   (show map): 19 km south-east of Moree   Investigation phase: Final report: Dissemination  
State: New South Wales   Occurrence type: Flight crew incapacitation  
Release date: 30 July 2021   Occurrence category: Serious Incident  
Report status: Final   Highest injury level: None  
Anticipated completion: 3rd Quarter 2021    

Aircraft details

Aircraft details
Aircraft manufacturer Piper Aircraft Corp  
Aircraft model PA-28R-201  
Aircraft registration VH-TBB  
Serial number 28R-7737153  
Type of operation Private  
Sector Piston  
Damage to aircraft Nil  
Departure point Moree, New South Wales  
Destination Scone, New South Wales  
Last update 30 July 2021