Etihad A6-DDE

A cargo flight from Abu Dhabi

Etihad Airways flight ETD 927 left Abu Dhabi International Airport for Amsterdam Schiphol on 27 September 2017. The Boeing freighter, registered A6-DDE, carried four people: the captain, the copilot, a loadmaster and a corporate security officer. Departure was at 0302 UTC, and the captain initially flew from the left seat. Takeoff and departure were uneventful, and communication between the pilots followed the operator's standards.

Both pilots were licensed and qualified, and both held valid Class 1 medical certificates. They had each flown four hours during the preceding seven days, and investigators found them adequately rested for the flight. The captain had renewed his medical certificate the day before departure. The aircraft was certified, equipped and maintained in accordance with UAE requirements. Weather and navigation aids were assessed as having no bearing on the incident.

Collapse in the galley

About 42 minutes after takeoff, the aircraft was cruising at flight level 320, approximately 32,000 feet. The captain handed control to the copilot, left his seat and went to the galley. As he pulled out a meal tray, he lost consciousness and collapsed in front of the security officer. The security officer immediately began cardiopulmonary resuscitation, or CPR. The loadmaster kept the copilot informed from outside the flight deck.

The loadmaster's first warning reached the copilot approximately six minutes after the captain had left the cockpit. Figure 1 places the captain's departure from the cockpit at 0344:28 UTC and the loadmaster's report of his collapse at 0350:51. At 0351:58, the copilot declared MAYDAY and contacted Kuwait air traffic control for a left turn. The report's synopsis records that Bahrain air traffic control was advised of the diversion.

The copilot chose Kuwait International Airport, which the investigation identified as the nearest available airport. After receiving clearance from Kuwait air traffic control, he began the diversion while continuing to operate from the right seat. He requested an ambulance for arrival at 0352:54. At 0355:17, the loadmaster reported that the captain remained unresponsive and that CPR was continuing.

An overweight landing and resuscitation on the runway

The aircraft still carried enough fuel for an overweight landing after its short flight. The security officer and loadmaster continued CPR as the copilot brought the freighter into Kuwait. Touchdown was at 0414:13 UTC, according to the flight path figure. The landing was uneventful, and the copilot stopped the aircraft on the runway so that paramedics could board.

The paramedics continued resuscitation for approximately 15 minutes before declaring the captain dead. The copilot, loadmaster and security officer disembarked normally. The aircraft was undamaged. An inspection required after an overweight landing found no defects, and the aircraft returned to service. Investigators assessed the copilot's immediate diversion and the security officer's sustained resuscitation efforts as giving the captain the best opportunity to survive. His medical condition was severe, and the resuscitation attempts were unsuccessful.

The medical evidence before and after the flight

An autopsy at the Kuwait City Coroner's Office identified a collapse of the cardiopulmonary system caused by narrowing of a coronary artery. The GCAA's Air Accident Investigation Sector concluded that this caused the captain's incapacitation and subsequent death. It found that his high cholesterol had caused coronary artery disease and contributed to the arterial narrowing.

The captain's medical records showed high blood lipid levels in October 2015. The operator's medical center advised changes to diet and exercise and arranged checks at three month intervals. His lipid levels improved in January 2016 but remained above the reference level. A further improvement in April was followed by the issue of a medical certificate valid for a year. High levels at the annual examination in October 2016 prompted another period of regular checks. By March 2017, the levels had fallen and the follow-up condition was removed.

Section 1.5.2 records a further medical examination on 26 September 2017. Lipid levels had decreased again, although they remained outside the reference range. Blood pressure, pulse and body mass index were normal, as was the electrocardiogram. The captain was 51, did not smoke, exercised regularly and followed a healthy diet. His calculated risk of atherosclerotic cardiovascular disease over ten years had fallen from 6.6 percent in 2015 to 3.2 percent at the latest check.

The calculation used for the medical assessment considered both modifiable and nonmodifiable risk factors. The GCAA guidance described a ten year risk below 10 percent as permitting certification once modifiable factors had been discussed and a management strategy recorded. Investigators concluded that the medical examiner could not have predicted the captain's imminent incapacitation.

Medication that had not been declared

Investigators found vitamins, aspirin, painkillers and statin tablets among the captain's belongings. His medical records contained no declaration of the use of these supplements and medications. Etihad's procedures and the applicable regulations required pilots to tell the aeromedical examiner about medication they were taking. Statin use was permitted under medical supervision.

The operator had already circulated medication guidance to pilots and cabin crew in 2015. Its medical center also provided information during induction and circulated material on medication use and fitness to fly. The investigation found that the captain's undeclared medication had likely helped reduce his lipid levels, while the treatment had proceeded outside the aeromedical examiner's management.

Declaring statin use could have given the examiner additional information about the reduction in the captain's calculated cardiovascular risk and allowed an assessment of the treatment. The GCAA could not determine whether the self-medicated statin use contributed to his incapacitation.

Freighter procedures and emergency assistance

Etihad's manuals described obvious and subtle pilot incapacitation and required an emergency declaration and an early landing. The procedures were written for passenger aircraft and depended on assistance from a cabin manager. The operations manual did not address two-pilot freighter operations. The incapacitation drill in the safety and emergency procedures manual also applied to passenger aircraft.

The security officer had to draw on earlier training when he began CPR. Etihad did not provide loadmasters and corporate security officers with regular first aid training, and UAE regulations did not require it. Investigators observed that many freighter flights carry only two pilots. When additional crew are carried, appropriate training and equipment can enable them to help during a medical emergency while the remaining pilot flies.

A6-DDE carried no automated external defibrillator, or AED. Such equipment was standard on passenger flights. The investigation could not determine whether an AED would have saved the captain's life. The aircraft's cockpit voice and flight data recorders were removed and taken to the AAIS recorder laboratory, where their data was downloaded successfully. Ground equipment had also recorded communications between the pilots and air traffic control.

Training changes and the final investigation

After the incident, Etihad added practical CPR exercises and pilot incapacitation material to initial and annual recurrent loadmaster training. Aviation health training for loadmasters and security officers was aligned with the cabin crew syllabus, apart from AED training, because B777 freighters did not carry those devices. Inflight security officers were required to attend practical CPR training and assessment.

Etihad also updated its operations manual and standard operating procedures for freighter pilot incapacitation, including the loadmaster's role. The GCAA distributed a fitness to fly brochure to UAE pilots and aeromedical centers, held a workshop for approved medical examiners on lipid management, and amended its lipid management guidance. The AAIS judged these actions adequate and issued no additional safety recommendations. Its final serious incident investigation report was issued on 25 February 2019.