B763, en-route, mid North Atlantic, 2011

B763, en-route, mid North Atlantic, 2011

Summary

On 14 January 2011 an Air Canada Boeing 767-300 was midway across the Atlantic Ocean eastbound at night when the First Officer, who had just woken from an exceptionally long period in-seat rest, suddenly but erroneously perceived a collision risk from oncoming traffic and without warning intervened to dive the aircraft before the Captain could stop him causing 16 occupant injuries. His behaviour was attributed to the effect of  sleep inertia following a much longer period of sleep than permitted by Air Canada procedures. It was concluded that many Air Canada pilots did not understand the reasoning behind these procedures.

Description

On 14 January 2011 a Boeing 767-300 being operated by Air Canada on a scheduled passenger flight from Toronto to Zurich and in the cruise at FL350 about halfway across the Atlantic Ocean experienced a sudden pitch excursion in Visual Meteorological Conditions (VMC) at night from which recovery was achieved but during which 16 of the 103 occupants were injured. After receipt of advice on the extent of the injuries, the flight was continued to the planned destination without further event and upon arrival, seven of the injured passengers were hospitalised.

Investigation

An Investigation was carried out by the Canadian Transportation Safety Board. DFDR data was available but the 2 hour Cockpit Voice Recorder (CVR) had not been stopped after the event and had consequently been overwritten. It was noted that a two pilot crew was operating the flight in accordance with the prevailing crewing agreement.

It was established that soon after the First Officer had been woken from a long period of in-seat ‘controlled rest’ by a routine radio call made by the aircraft commander and soon afterwards had been appraised by him of expected opposite direction traffic 1000 feet below, a USAF C17, which was evident as a Airborne Collision Avoidance System (ACAS) target on the ND. The First Officer then apparently mistook the planet Venus for an oncoming aircraft but was re-advised by the aircraft commander of the traffic 1000 feet below.

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