Description

On 21 July 2022, an Airbus A320 (PK-GLW) operated by Citilink Indonesia on a scheduled domestic passenger flight from Surabaya to Makassar as CTV307 declared a PAN to return to land when, after takeoff in day visual conditions (VMC), the captain was observed by the first officer to have become incapacitated. The return to land was successfully accomplished by the very low-experience first officer acting alone. Despite resuscitation efforts by a passenger who was a qualified doctor, the captain could not be resuscitated and was subsequently confirmed deceased.

Investigation

An investigation was carried out by the Indonesian National Transportation Safety Committee (NTSC) - the Komite Nasional Keselamatan Transportasi (KNKT). Relevant data was downloaded from both the cockpit voice recorder (CVR) and flight data recorder (FDR), and a comprehensive record of the captain’s medical history was available.  

The total flying experience of the 48-year-old captain, who had been acting as pilot monitoring (PM) for takeoff, was not recorded but he had flown 166 hours on type in the 90 days prior to his sudden incapacitation. The 26-year-old first officer had completed training as an A320 second-in-command four months earlier. Incapacitation training was included in his full flight simulator type training, but he had never been trained to taxi the aircraft nor had he had any experience in doing so.

What Happened

Takeoff was performed with the aircraft in ‘packs off’ configuration so as to maximise engine thrust. This procedure increases engine power by turning off the air conditioning system, which reduces the bleed air demand on the engines. After takeoff, the tower controller instructed the flight to change to approach control for radar service, and the captain acknowledged and actioned the instruction. When the captain called approach control, the flight was cleared to climb to FL230 and routed direct to an en route waypoint which was about 50 nm away. One minute after takeoff, as the aircraft was passing 2,400 feet, an electronic centralized aircraft monitor (ECAM) caution indicated that air conditioning pack two was still selected to ‘OFF.' The first officer, aware that the captain would normally have switched this on once safely airborne, then saw that the captain “was in a rigid position." He attempted to check if the captain was conscious but there was no response and he subsequently stated that at that point, he had “assumed that the captain had fainted."

The first officer called the senior cabin crew member (SCCM) on the interphone, requested that person to come to the flight deck and said the captain was incapacitated. An announcement was made requesting medically qualified passengers to make themselves known, and the first officer made a PAN call to the airline, advising the company of the situation and his intention to return to Surabaya. Five minutes after takeoff, by which time the aircraft was passing 13,000 feet, the first officer then made a PAN call to air traffic control (ATC). The flight was cleared to stop climb, turn around and descend to a waypoint which was located about 14 nm from runway 28 at Surabaya. The first officer was advised to call again when ready to make an approach. Meanwhile, one of three passengers who had identified themselves as medical doctors was invited to assist after a portable oxygen bottle and the aircraft emergency medical kit were delivered to the flight deck. Attempts to resuscitate the captain made with the assistance of two of the cabin crew were not successful. The first officer confirmed to company that an ambulance would be required on arrival and after 20 minutes airborne, the first officer advised ATC that the flight was ready for an approach. A required navigation performance (RNP) approach to runway 28 was approved.

Transfer to tower followed and a landing clearance was issued. The aircraft was configured for landing but at around 2,000 feet, the first officer assessed that preparation for landing was not going to be completed in time because resuscitation attempts were continuing. The first officer declared a go-around with a request to reposition for an approach to runway 10. After a further five minutes during which the medical doctor and the assisting cabin crew returned the captain to his seat, the first officer advised the tower that the flight “was establishing on the runway 10 ILS localiser." After a landing clearance, touchdown occurred after 41 minutes airborne. The subsequent taxi in to Terminal One was completed and on arrival there, the passengers were temporarily held on board whilst airport medical personnel boarded the aircraft to examine the captain’s condition. The captain was moved to an ambulance and taken to a hospital where he was pronounced already deceased with time of death unknown.

Why It Happened

A review of the captain’s medical history as retained in his licence medical certification renewals was carried out. His records showed that for the last five years his cholesterol level had “constantly exceeded the normal value determined by the Aviation Medical Centre” and that he was overweight and an active smoker. However, although guidance to medical examiners “described high cholesterol level, smoking, and obesity....as vascular risk factors which can increase risk of coronary events such as heart attack," there were no regulatory requirements for “pilots with vascular risk factors to be assessed as unfit during medical examination." However, the guidance did state that “vascular risk factors should lead to intervention even before the declared disease, especially if there are multiple risk factors present”. As a consequence, the captain had been recommended at every medical examination to change to a low-fat diet and take routine exercise as well as to quit smoking, although there appeared not to have been “any referral for a statin therapy to reduce the high cholesterol level nor any information that he was on statin therapy." In the last medical examination prior to incapacitation all the vascular risk factors remained.

The last resting ECG prior to his death had been performed in 2021 and had indicated that he had an abnormal sinus rhythm indicating “inferior ischemia.” This meant that a regular heartbeat was accompanied by “decreased blood flow to the basal part of the heart caused by blockage of the coronary artery." The anomaly should have been further examined in accordance with relevant guidance but this did not occur, and an authorised medical examiner (AME) determined that the captain was fit to fly. 

Six months later, the captain’s next routine medical examination took place about one month before the incapacitation event and included an exercise ECG which was terminated early because he had reached his maximum heart rate. This meant he did not meet the minimum performance requirements for an exercise ECG. The result was sent to a cardiologist, and a heart abnormality was diagnosed. The cardiologist reported marking the exercise ECG result as “negative” and ordered a CT scan to be performed to better inform on the abnormality. However, the cardiologist’s communication of his findings was lost in transit, which resulted in a “lost opportunity to have a more comprehensive review of the captain’s cardiovascular condition." 

An examination of the pilot incapacitation procedures in the operations manual (OM) Parts ‘A’ and ‘B’ was carried out and a series of deficiencies were found. These included but were not limited to the absence of any pilot checklist on that procedure, meaning the remaining pilot must have memorised all the specified actions or open the respective documents to refer to them during implementation. Without any checklist, it was concluded that “an incapacitation event during high workload situation such as takeoff, might add pressure to the fit pilot and affect their capabilities to remember the procedure correctly, especially since the procedure contains many sequenced actions." Overall, it was considered that these “deficiencies in the pilot incapacitation procedures might prevent the effective implementation of the fit pilot’s and [cabin crew's] actions when dealing with a pilot incapacitation event."

Despite the overall success of the first officer’s management of the emergency, the investigation noted that he had advised being ready for an approach when the doctor and the cabin crew were initiating CPR. It was considered that “proceeding with the landing approach before completing flight preparation and resuscitation process indicated that the approach preparation was not done properly." It was also noted that although a first officer in the right seat is not allowed to taxi an A320, in the event of pilot incapacitation, they were permitted by the OM Part ‘B’ to do so to “vacate the runway to a safe area” before requesting that the aircraft be towed to the apron. This was because first officers did not have training or experience in taxiing. It was, however, accepted that the captain had been in need of urgent medical assessment. Overall, it was concluded that “the series of pilot actions during the occurrence indicated that the prescribed sequence of actions in the OM-A and the detailed guidance in the flight crew training manual (FCTM) were not implemented properly."

Two Contributory Factors were identified and recorded as follows:

• The absence of a further and fuller review to clarify the anomaly indication during the last resting ECG, the duration of exercise ECG which was less than nine minutes, and the absence of heart computed tomography (CT) scan during the last medical examination resulted in a lost opportunity to have a more comprehensive review of the captain’s cardiovascular condition.
• The possibility of cardiovascular events resulting from inadequate intervention measures to mitigate vascular risk factors might have led to the captain’s incapacitation.

A total of Seven Safety Recommendations were made based on the Findings of the Investigation as follows:

• that Citilink Indonesia establish a health monitoring system as mandated by DGCA Circular SE 06 Tahun 2022 which ensures medical interventions to reduce health risk (to pilots) are implemented properly. [04-2022-10.01]
• that Citilink Indonesia review the reference documents on pilot incapacitation training to ensure that this training is conducted using current and valid document to avoid confusion during its implementation. [04-2022-10.02]
• that Citilink Indonesia evaluate the training materials to ensure that a flight attendant can administer oxygen as soon as it needed, including proper use of a pilots quick-donning oxygen mask. [04-2022-10.03]
• that Citilink Indonesia reviews its crew incapacitation procedure to consider the potential benefits of involving more than one medical doctor in handling an incapacitation event. [04-2022-10.04]
• that the Aviation Medical Centre consider an exercise ECG (performance) that does not meet the minimum requirement of three stages (nine minutes) or an oxygen uptake equivalent to 11 Metabolic Equivalents (METs) as a potential risk for subsequent cardiovascular event which must trigger further evaluation. [04-2022-10.05]
• that the Aviation Medical Centre evaluates the procedures for reporting the ECG results so as to ensure that all instructions from the cardiologist are delivered and performed appropriately. [04-2022-10.06]
• that the Directorate General of Civil Aviation reviews Staff Instruction (SI) 67-02 to ensure (that) the anomalies identified during (a) resting ECG are clarified for a more comprehensive review of the applicant’s cardiovascular condition. [04-2022-10.07]

The Final Report of the investigation was approved for publication on 2 September 2025 and subsequently released.

Related Articles

• Pilot Incapacitation
• Pilot Fitness to Fly
• Lifestyle and Adverse Performance Effects (OGHFA BN)
• Flight Crew Licensing