Investigation number
AO-2023-026
Occurrence date
Location
Hobart Airport
State
Tasmania
Report status
Pending
Investigation level
Defined
Investigation type
Occurrence Investigation
Investigation phase
Examination and analysis
Investigation status
Active
Aviation occurrence type
Flight crew incapacitation
Occurrence category
Serious Incident
Highest injury level
Minor
Anticipated completion

The Australian Transport Safety Bureau (ATSB) is investigating a flight crew incapacitation incident involving Boeing 717-200, VH-NXM, on approach to Hobart Airport, Tasmania on 06 June 2023.

Passing 3,000 ft on approach, the captain noticed a chlorine-type smell and shortly after assessed themselves as unable to continue as pilot flying due to the onset of hypoxia-like symptoms. The first officer took over as pilot flying, with the captain performing pilot monitoring duties. The first officer later reported that they started to feel the onset of deleterious symptoms on short final. The aircraft landed without further incident.

The ATSB has commenced the examination and analysis of the initial evidence collected. To date, the ATSB investigation has included:
•    interviewing the flight crew and support crew
•    examination of maintenance and pilot records
•    analysis of flight data recorder and air traffic surveillance data
•    examination of the operator's suite of manuals
•    analysis of the crew actions. 

In the course of the investigation, the ATSB has identified risk controls with limitations that potentially contributed to the occurrence. Examination of these factors represent a significant increase in the scope of this investigation, and it has been upgraded from Short to Defined. As a result the report will include an expanded analysis to support the broader set of findings within the report and may include safety factors not relating directly to the occurrence. Defined investigations may also identify safety issues (safety factors with an ongoing risk) relating to ineffective or missing risk controls. The report also identifies safety issues, along with proactive safety action taken by industry and ATSB safety recommendations.

The continuing investigation will include further analysis of:
•    operational documentation
•    related occurrences
•    analysis of air traffic control voice recordings.

A final report will be released at the conclusion of the investigation. Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties, so that appropriate safety action can be taken.

Last Updated
Aircraft Details
Departure point
Sydney Airport
Destination
Hobart Airport
Model
717-200
Serial number
55094
Sector
Jet
Registration
VH-NXM
Operation type
Part 121 Air transport operations - larger aeroplanes
Damage
Nil
Manufacturer
The Boeing Company
Aircraft Operator
National Jet Systems Pty Ltd