Dealing With In-Flight Incapacitation

What does that really mean, at least in flying? How do I recognize it? How do I respond? You may have discussed this topic with your flight instructor at some point in your training—what to do if a passenger or crewmember becomes incapacitated. It may have seemed to be a “what-if” exercise.

That is, until it happens on your airplane. 

A few years ago I was flying in my day job for a major air carrier on what I thought was an easy two-day trip—one leg from New York to San Francisco, a long layover, and then one leg back to New York, arriving around midnight the second day. Piece of cake. 

I met my first officer, Sue (not her real name), in the pilot lounge. I had never flown with Sue. 

Although very experienced, she was relatively new to the Boeing 757. In fact, she was coming up on her first annual recurrent training in a few weeks.

I flew the first leg from KJFK to KSFO, and the flight consisted of us flying while, at the same time, doing what most pilots do— talking about family, kids, job, all the normal stuff. She asked me about the upcoming recurrent training and what to expect. Sue was a good FO, knew her job, and it made for a pleasant trip on day one. We arrived that afternoon, got transported to the hotel, and then went our separate ways. 

After a good night’s rest, a little exercise, lunch, and a quick nap, I met back up with Sue the next day at pickup time. As I usually do with my FOs, I jokingly asked Sue if she had a “successful layover.” She looked a little tired and commented that she had not slept very well that night. I made some sort of comment about it only being a four-hour, one-leg flight to JFK, and that we would be there before we knew it. That was my first opportunity to question Sue about her physical condition. And I missed it. 

We got to the airport, readied the airplane, pushed back, taxied out, and took off. It was Sue’s leg. We got up to altitude, Sue engaged the autopilot, and we headed east. This leg was a much quieter one than the day before. Sue barely spoke. I thought it a bit odd, but wasn’t too worried about things.

About an hour or so into the flight, the flight attendants called up and offered us our in-flight meals. They took our orders of food and drink, came up a few minutes later with our meals, and we began to eat. Or, I should say, I began to eat. Sue kind of pushed her food around and commented, “Man, I am just not hungry.” That was opportunity number two. And, yet again, I missed it. 

A few minutes later, the flight attendants came and took the trays, and we settled back into a quiet flight. Not long after, Sue said to me, “Do you mind flying the airplane?” and I, of course, said, “Sure.” She leaned her seat back and leaned her head back. I assumed that she had a bit of a headache, and again, let it go at that. That was opportunity number three. And, yes, again, I missed it.

I have to interject here that after almost 29 years of flying, I have seen pilots who have not felt well but never seen one become incapable of flying while in flight. It just is not the norm. I know that Sue was aware of things, as the flight attendants just moments later called up asking us to warm up the cabin. Before I could adjust the cabin temperature, Sue had reached up and was making the adjustment. She had heard the call and was responding, so I settled back into the dark cockpit, not really worrying too much.

Not yet, anyway.

I glanced over at Sue a bit later, and she was sitting quietly. I turned to my left to grab something out of my flight bag, and seconds later I heard a noise, a commotion. It sounded like someone was banging the side of their chair. I looked over and there was Sue, in the only way that I can describe, flopping like a fish. She had slid down sideways in her seat, held away from the yoke only by her shoulder harness, and was flopping back and forth, uncontrollably. My first thought was, “That’s not very funny, Sue,” until I saw the drool coming out of the side of her mouth and her eyes rolled back.

This wasn’t some joke. This was real. My second thought was,“&%#?*&!” I like to say that all emergency responses start with a cuss word, and this situation was no different. I said my word of choice, and my next thought was, “We have to get on the ground—now.”

The agents in San Francisco had told me before we left that there would be no non-revs on the full flight. I also knew, as the captain, that there were no deadheading crew on that flight. No other pilots. It was just me. And 180 passengers. And four flight attendants. And Sue. Incapacitated. 

Whenever you have an emergency, my company likes to teach that there are always four calls—two out, and two in. The calls in refer to first, the flight attendants, then the passengers. The calls out are to ATC and the company. The calls are not always in a particular order—they just need to be done.

My first call was to ATC. I informed them that we had a medical emergency in the cockpit and that I was calling the company and would inform it of our intentions after that. The next step was to call the company. Thank God, our company had satellite phone communications on that 757 that night. At that time not all 757s did.

I called the company, spoke with my dispatcher, and discussed options. “You are just northeast of Fargo [North Dakota]. We could put you in there.” I thought about that, but decided against that as Fargo was not a mainline destination. At some point the airline would have to get a new crew to the airplane. Fargo would not be easy. 

I suggested Minneapolis, as it was a mainline destination that it could get crew to, and it was not much farther than Fargo. Besides, Minneapolis was more likely to have the better medical facilities of the two options.

The dispatcher agreed, I asked him to make it so, and hung up the sat phone. I next called the flight attendants and told them I needed a flight attendant up in the cockpit because we had a medical emergency. When they asked where the medical emergency was, I told them “in the cockpit.” It got silent over the interphone. But within a few seconds, I had Natasha, a flight attendant, in the cockpit with me. 

Sue had been lifeless for several minutes, and for most of those I had assumed that she was dead. She did not appear to be breathing, at least at first. About the time Natasha came in, Sue gasped and started to come around. “What, what. I don’t understand” was all she could manage to say in a weak voice. I told her that she appeared to have had a seizure, had become incapacitated, and that I was now flying the airplane. She could no longer touch the controls.

I informed ATC of our intentions, and they cleared me to turn left directly to KMSP. In a debrief later, I was told by the dispatcher that from the time we hung up the phone until the time we landed at Minneapolis was 29 minutes—29 long, busy minutes.

My last of the four calls was to the passengers, and I informed them that there was a medical emergency on the airplane and that we were diverting to Minneapolis. I would answer further questions on the ground, but for now, that was all they needed to know. 

It was a clear night. One of those “clear and a million nights,” but I did not want to take any chances. ATC initially cleared me direct to the airport, but I asked to be cleared to the outer marker for the ILS approach to Runway 12R. ATC complied, and I set up for a coupled approach. I wanted to make the approach and landing as normal as I could.

I kept the autopilot on until approximately 1,000 feet agl. I disconnected the autopilot and made a normal landing, turned off on the first high speed taxiway, and was at the gate less than three minutes after landing. EMTs came on board and escorted Sue off the plane.

I came out of the cockpit, stood at the front galley of the airplane, and made a PA announcement while facing the cabin. I explained that my copilot had become incapacitated with a possible seizure and that had caused the emergency divert. (I suspect I may have broken medical privacy laws by stating that, but I felt that the passengers deserved to know). I walked through the cabin and thanked the people eye to eye. I felt that they deserved that as well.

I then left the airplane to the agents for another crew to arrive and continue the flight. I was headed to the hospital to make sure Sue was OK. 

So, what did I learn from this? 

Watch for signals: I missed several signals that Sue was not ready to fly. From lack of sleep, to a change in her demeanor, to the lack of appetite, to asking for me to take the plane. All were signals, and I missed them. So how does this apply to GA flying? I now ask passengers directly at the beginning of every flight, “How do you feel? Do you feel up to flying today?” Maybe if I had asked Sue, we could have avoided the situation that we found ourselves in a few hours later. Maybe by asking that simple question you can avoid a similar emergency. 

Use the assets available: I had a sat phone and a company dispatcher. Most likely, you do not. But you do have ATC. Controllers can be your best friends in a similar situation. Electronic flight bag tools, glass cockpits, and ATC can all combine to give you the situational awareness that will allow you to make the best decision as to where to land. 

Use all tools available: I stayed on the autopilot until about two minutes prior to landing. I did not want to overload myself by trying to hand-fly the aircraft. The autopilot is a tool to use in such a situation. I coupled up to an approach even though it was a clear night. Those were all tools available to minimize the workload, and I used them. 

Consider options carefully: Don’t assume that your nearest landing option is your best one. It does you little good to land at Podunk County Airport that has no crash crew or medical staff, with the nearest emergency room 45 minutes away, when you could have flown 10 minutes farther to an airport minutes away from that same emergency room. Think for a moment, and don’t just react. 

Keep people informed: I mentioned that my company teaches four calls are needed. But you may not have a dispatcher or flight attendants. But you do have at least two calls to make—to ATC and to notify passengers. Discuss with ATC your options, but make sure your passengers know that you have a plan. Tell them your plan, so that they can feel like, even though there is an emergency, it is a controlled one. 

Trust yourself: Simply put, if I can fly a 757 with only one pilot, you can fly your GA airplane in an emergency and still land safely if you rely on your training and remain clear-headed. 

This story has a semi-happy ending. Sue is fine. Unfortunately, her piloting career is most likely over, but she is well, and home with her family. She is raising her family and focusing her life in new directions.

As for me? I learned to ask questions sooner and not assume that all is well, even when signs indicate otherwise.

This feature first appeared in the September Issue 950 of the FLYING print edition.