Ladies and gentlemen, your pilot is unconscious

An official incident report has confirmed that a Lufthansa Airbus A321 flight from Frankfurt, Germany to Seville, Spain on 17 February last year flew for 10min without any pilot supervision because the copilot, alone on the flight deck at the time, suffered a “sudden and severe incapacitation” which was defined in the report as a “seizure”.

An experience of my own many years ago was strikingly similar to this, so we will return to that subject in a moment after examining the events on Lufthansa’s Frankfurt – Seville flight last year.

Once Flight LH77X was established in the cruise over northern Spain at flight level 350 (35,000ft), carrying six crew and 199 passengers, the captain discussed pertinent weather conditions on the route with the copilot, who was the pilot flying, and then left the flight deck for a toilet break at 10:31:00 (UTC). Exactly 36 seconds after the captain had left the flight deck, the copilot suffered an epilepsy-like seizure, according to the Spanish accident investigation authority CIAIAC.

There was no immediate indication to the absent captain that anything was wrong, because the autopilot and autothrust remained engaged, despite some inadvertent switch selections by the copilot, and the fact that his right foot was pressing the rudder pedal hard – but fortunately not hard enough to cause the autopilot to trip out.

Meanwhile the sector controller for Spain’s Pau ATC region attempted three times to establish radio contact with LH77X, but received no reply.

At 10:39:00 the captain was ready to return to the flight deck, and he attempted a standard entry procedure, but there was no response from the copilot who would have had to approve it. After three further attempts he decided to employ the flight deck emergency access code, but while he was doing that the copilot, “pale, sweating and moving strangely”, opened the door from the inside.

The captain took control of the aircraft at 10:42:00, and at his request the cabin crew helped the copilot into the forward galley area, administered first aid, and obtained the help of a doctor from among the passengers. Meanwhile the captain decided to divert the aircraft to Madrid, the nearest airport, rather than continuing to Seville. The A321 landed safely and the copilot was taken to hospital, but released after examination.

The CIAIAC report quotes the definition of a “seizure” under these circumstances as “an abnormal paroxysmal excessive discharge of cerebral cortical neurons”. The copilot had no medical record of any such event previously, and said he had not experienced anything like it before. The medical judgement as reported by the CIAIAC is that, even had the copilot been tested specifically for such a condition, it would not have been detectable unless he had suffered a seizure in the presence of a medical observer.

The report’s main recommendation for the future is that, any time one of the pilots has to leave the flight deck, a member of the cabin crew should join the remaining pilot in the cockpit until the absent pilot returns. This is actually a previously established procedure which had fallen into disuse simply because incapacitation is so rare. But if it had been applied in this case, the cabin crew would have been able to alert the captain immediately about the copilot’s condition, and help him re-enter the flight deck quickly.

Meanwhile here is an account of my personal experience of airborne seizure – and precursors to it – that is highly relevant to cases like this one.

During my time as a qualified flying instructor (QFI) in the RAF I had gradually developed a condition which caused me to suffer minor seizures which, at the time, I did not recognise. They just felt like momentary mental “absences” that I attributed – for example – to having had a few drinks too many in the Officers Mess the night before. At the time I was in my late 20s, and had been flying pressurized jets and turboprops for eight years,

But my wife noticed these “absences”, and reported them to an RAF doctor who then approached me about them. I dismissed the matter as unimportant, and he did not pursue the issue further.

I recall having an “absence” while on short final approach to land a Jet Provost, solo, at RAF Linton on Ouse. I can’t actually remember the touchdown itself, but can remember rolling out at the end of the runway and turning onto a taxiway back to the pan, by which time I felt fine. But the thought of this event – now that I know more about my condition at that time – chills me.

Some months later I suffered a fully-fledged seizure during my sleep, and my wife called the doctor, who attended immediately. When I awoke I felt as if I had been beaten up.

I was taken to an RAF hospital and tested via electro encephalograph (ECG), and underwent brain scans. The diagnosis – given the evidence of the seizure – was that I was “probably” prone to epilepsy, but the condition was defined as “idiopathic”, meaning there was no medically detectable sign of it.

Continuing to fly professionally after that was not an option, so I left the RAF and became an aviation journalist.

At the time I believed my symptoms might have been caused by an sudden and unexpected application of quite high negative G during a practice aerobatic sequence flown by one of my student pilots. But the medics could find no sign of brain damage.

Over the decades since that time, in my job as an aviation journalist, I learned about “Aerotoxic Syndrome”, the name given to a condition caused by damage to the brain and nervous system by neurotoxic chemicals from aero engine lubricants and hydraulic fluids. High doses, gained via a “fume event” in the cockpit or cabin, can cause instant cognitive problems, although these may fade with time. But in other individuals, regular exposure to low doses of neurotoxins over a long time can gradually build up in the body, degrading the nervous systems of pilots and cabin crew.

These organophosphate chemicals, containing known neurotoxins, are delivered to the cockpit and cabin by aircraft air conditioning and pressurization systems, where the air is sourced directly from jet or turboprop engine compressors. Engine oil seals constantly leak fluid at low levels, so when the highly compressed – and therefore hot – air is delivered to the air conditioning system, it contains pyrolized neurotoxic aerosols. This is the air that the crew breathe.

In some individuals, that constant low-level poisoning builds up in their system until it causes visible symptoms of neurological damage. In other individuals, their systems gradually purge the chemicals, making symptoms last only a short time. But so far there is no way of knowing in advance which kind of system individual aircrew have.

In my case, today I no longer have even slight seizures, neither do I have to take any medication which, for more than 25 years, I had to do constantly to keep the symptoms at bay. Neurologists say, nonetheless, that they cannot declare me free of epilepsy or related neurological conditions because they still do not know enough about the subject to be certain. I suspect what has happened is that, since I left the RAF, I fly only occasionally, so my system has had time to purge itself of the neurotoxins that regular flying delivered to me.

I wish the Lufthansa copilot of flight LH77X on 17 February 2024 well, and hope he gets all the support he needs to continue his career, if that is deemed possible.

Meanwhile for him, and all those who want to know more about Aerotoxic Syndrome, FlightGlobal has a useful account here.

Shoreham and the future of air shows

No person or organisation associated with the 2015 Shoreham flying display accident escaped criticism – implied or actual – in the Air Accident Investigation Branch’s final report.

When the aircraft that later crashed, the Hawker Hunter T7, took off from its North Weald, Essex base heading for Shoreham to fly the display, it had several time-expired or unserviceable components in it. In retrospect the AAIB report says it was not in compliance with its permit to fly, yet none of these faulty components caused the accident.

The Flying Display Director hired to manage show safety was fully qualified in terms of knowledge, experience and expertise to oversee all aspects of the flying display, but the report implies there were some things – like the exact display routine the Hunter was to fly – he should have risk-assessed manoeuvre by manoeuvre. Yet even if he had, the crash might still have happened.

The Hunter’s pilot was fully qualified in terms of experience, training, flying recency and medical fitness to carry out the display he had planned, but on the day he got one of the aerobatic manoeuvres badly wrong, making mistakes that are difficult to understand in somebody so experienced.

The mistakes meant that he himself was seriously injured when thrown clear of the aircraft on impact with the A27 highway next to the airfield, but 11 people on the road were killed.

By flying a similar Hunter through the same manoeuvres, the AAIB has determined that the pilot could not have pulled the aircraft out of his “bent loop” without hitting the ground once he had passed the apex too low and failed, at that point, to carry out an “escape manoeuvre” by rolling the aircraft upright.

If he had used his ejection seat during the high speed descent from the loop it would not have saved him, and the pilotless aircraft would have continued to impact with the ground, possibly in much the same place. The only way the pilot could have prevented killing the people on the A27, says the report, was to crash the aircraft into nearby fields, but during the last second or so he probably still hoped he could avoid harm to road-users by pulling up in time.

Why was he too low at the loop’s apex?

He should have entered the loop from a 500ft base, but he started at about 185ft. The height of the top of a loop compared with the entry height is a product of speed and engine power at entry. The aircraft should have entered at a minimum 350kt with full power selected, but the Hunter entered at 310kt with less than full power until well into the pull-up. The pilot should have aimed for a 4,000ft apex with 150kt indicated airspeed over the top, but in fact it got to less than 3,000ft with 105kt.

Unless the pilot recognised the lack of energy at that point and carried out the rolling escape manoeuvre, he and the aircraft were doomed.

Why a pilot with so much experience of teaching, let alone flying, aerobatic manoeuvres failed to heed these indicators that the loop was going wrong may never be known, because trauma has obliterated the details of the fatal flight from the pilot’s memory, according to the report.

Air shows involve risk. A study by the AAIB has recently quantified that risk, and my blog a year ago describes the findings in detail.

The final Shoreham report confirms the impressions given by the earlier AAIB bulletins on the subject. Because no-one in an on-site air display audience in UK has been killed since the early 1950s, such success appears to have led to complacency.

Not rampant complacency, but a relaxed belief that all the people involved are experts who know what they are doing, so they don’t need to be given the third degree before a show.

The sign that not all was well was the number of serious air display accidents, mostly fatal, that occurred just outside the area controlled by the display organisers – just like the Shoreham Hunter crash.

The AAIB found that 65% of all air show accidents came into that category, but almost always the only person harmed was the pilot. So nobody, including the CAA, raised the alarm, until now.

Meanwhile aerodromes used for decades as air show venues have suffered encroachment at their boundaries by expanding residential and industrial development. This affects the profiles aircraft are allowed to fly during a display, and flight display directors are bound to take this into account.

No longer are display lines, and entry and exit profiles dependent purely on where the display audience “crowd line” is, they have to take into account what each aircraft would have to do in the event of a technical or operational mishap during the display to avoid crashing into a nearby populated zone.

These are considerations that will affect air shows in the future. If a flying display stops being exciting, it might as well give up. Or go somewhere else more rural.

Coastal air displays will survive, because the escape route for aircraft in trouble is obvious.

The best example of the conundrum air show organisers face is what has happened to the traditional Red Arrows display at the biennial Farnborough International Air Show. When the Reds reviewed their Farnborough routine in detail following the tightened guidelines published in the early Shoreham bulletins, they found they had to curtail their display considerably.

In a statement following the release of the Shoreham final report, the CAA says: “We are fully committed to ensuring that all air shows take place safely, for the six million people who attend them each year in the UK and for the communities in which they take place.”

Let’s hope the CAA means what it says.