Safety issue
| Safety issue description |
The Airservices Australia hypoxic pilot emergency checklist did not contain guidance on ceasing the emergency response. This increased the risk that a controller may inappropriately downgrade the emergency response during a developing hypoxic scenario. |
|---|---|
| Issue number | AO-2023-053-SI-01 |
| Issue owner | Airservices Australia |
| Transport function | Aviation: General aviation |
| Issue status | Closed – Adequately addressed |
| Date issue released | 19/06/2025 |
| Issue status justification |
In response to the safety issue, Airservices Australia made amendments to the in-flight emergency response (IFER) hypoxia checklist that likely reduce the risk of a controller inappropriately downgrading an emergency response during a developing hypoxic scenario. |
| Issue finalisation date | 15/09/2025 |
Safety action
| Action type | Proactive action |
|---|---|
| Action number | AO-2023-053-PSA-01 |
| Organisation | Airservices Australia |
| Action description |
Airservices stated that it is: committed to continual improvement of our systems and procedures and to that end, we are reviewing the IFER [(in-flight emergency response)] checklist to include further consideration of the need to suggest descent to a pilot where hypoxia is suspected, even after an operations normal report is received. |
| ATSB response |
The ATSB recognises Airservices’ intention to undertake a review of the IFER checklist. The ATSB will monitor the outcome of the review and any action taken towards the satisfactory resolution of this safety issue. |
| Action status | Closed |
Organisation response
| Date received | 11/09/2025 |
|---|---|
| Organisation | Airservices Australia |
| Response text |
On 11 September 2025, Airservices Australia advised the ATSB that the IFER hypoxic pilot emergency checklist had been reviewed and amendments made to include additional symptoms and actions for the air traffic controller to consider when managing a hypoxia scenario. This included an option for an air traffic controller to continue the emergency response in situations where the pilot had indicated operations were normal, but air traffic control had continuing doubts. The amendments to the checklist are effective from 27 November 2025. |
| ATSB response |
The amendments made to the Airservices Australia in-flight emergency response (IFER) hypoxia checklist likely reduce the probability of a controller inappropriately downgrading an emergency response during a developing hypoxic scenario. |
| ATSB response date | 15/09/2025 |