Contaminated Aircraft Air and Aviation Safety
Source: Aviation Contaminated Air Reference Manual
Definition of Safety © 10th April 2008 by Susan Michaelis While aviation safety ought to be based upon an aircraft’s ability to meet the regulations, it is clear that the aviation industry’s definition of air safety is very different. British Aerospace advised the Australian Senate Inquiry looking at contaminated air in 2000 that of its 350 BAe 146 aircraft operating in 27 countries with 52 airlines:
The BAe 146 has never suffered a passenger fatality or a fatal accident due to technical failure in more than 4.5 million hours of operation. [52]
When questioned by Senator O’Brien of the Australian Senate Inquiry committee looking into these matters, British Aerospace very clearly stated that the measure of an aircraft’s safety record was measured in terms of the aircraft having, ‘not had a fatality due to a technical problem, and that is the criterion.’ Senator O’Brien clearly stated that he was keen to draw out that airlines use the term that its aircraft is ‘safe’ by ‘getting the passengers from here to here, point A to point B, without tragedies or disasters.’ This is clearly supported by the BAe acknowledgement that the definition of aircraft safety records was based upon the lack of aircraft accidents causing fatalities due to a technical fault. [17] This view of when an aircraft is deemed safe completely without any doubt, ignores many issues that occur before a fatal accident for ‘technical reasons’ occurs, including cabin air contamination. The fact that an aircraft could crash based on non technical reasons such as pilot error, perhaps due to contaminated air, do not even fall into the aviation industry definition of ‘safety.’ This is an extremely worrying situation that needs urgent review.
Numerous in flight incidents are showing the serious flight safety issues linked to contaminated air exposure. In this chapter we will refer a lot to the British Aerospace BAe 146 as an example as it has been linked frequently to the contaminated air issue. However, contaminated air events have occurred on nearly all commercial aircraft types with some types having significantly higher number of events such as the Boeing 757, Airbus A320 and MD80. This is essentially because contaminated air as acknowledged previously is a function of bleed air system design and all engines will leak. [14][38] Had contaminated air not had a health part of the debate with massive potential financial implications to the airline industry it may be that the issue would have been addressed by now.
Kolver and Malmo Incidents
Despite years and years of contaminated air exposure events and extensive documented history showing such oil leaks were occurring since the BAe 146 entered airline service in 1983 (see appendices and other data in this manual), adequate steps were not taken to address the problem. Two well reported major flight safety events occurred on the BAe 146 that should have logically and finally forced the airline industry to act but they regrettably adopted a business as usual attitude. The first occurred in Australia on 10 July 1997 and became known in the trade as the ‘Kolver Incident’, [24] a mere 20 years after the 1977 paper by Dr Weir. [22] The second occurred on 14 November 1999 in Sweden and became known as the ‘Malmo Incident’ in which fumes were smelt over 3 sectors. [59] In both these incidents contaminated air affected at least 2 pilots and in the later case the cabin crew as well. These incidents are discussed more in Chapter 8 & 9. As in all contaminated air events emergency oxygen was available for the pilots to use to enable them to land the aircraft in an emergency and, theoretically, significantly decrease the immediate risk to the aircraft and its occupants. However, emergency oxygen was only used by the pilots in 1 of these four sectors and not immediately contaminated air was suspected in any case. We say in theory because having failed to tell pilots and crews for years that exposure to contaminated air was a health or flight safety concern, most crews like the crews on these incidents simply ignored contaminated air as it had become a normal part of the job. The airline industry, however, started to see the writing on the wall for an accident because crews were becoming incapacitated during contaminated air events despite emergency oxygen being available to the pilots to potentially stop this. This placed the aviation industry in an awkward position, how to minimise the risk of losing an aircraft but without admitting to the crews and passengers of the full health and safety risks and taking costly steps like with TCAS to do something.
What forced the airline industry to finally take some action was the ‘Australian Senate Inquiry’, [60] which will be reviewed in greater detail in Chapter 18. The Inquiry concluded in October 2000 that contaminated air on the British Aerospace BAe 146 was not just a flight safety issue but also that crews were getting sick. It also found that unlike the industry statements that this was not an air safety issue, the aviation regulations clearly showed that it was a safety issue by virtue of the fact that there are regulations which, ‘require pilots to be in a suitable state of health for flying an aircraft and therefore acknowledges the regulatory link between crew health and air safety’. [60] The inquiry was an embarrassment to the airline industry as it showed clearly what was going on and the way the airline industry and in particular British Aerospace had been unsuccessful in dealing with contaminated air issues for almost 20 years and longer in general.
Seeing without doubt what was coming from Australia, the UK Government, in an effort to protect the British Aviation industry, decided to get its pending inquiry into ‘Air Travel and Health’ to also supposedly investigate the contaminated air issue. The task was given to the Select Committee on Science and Technology and it is now referred to as the ‘House of Lords Inquiry.’ [61] The House of Lords Inquiry which we take a good look at in Chapter 18 started taking ‘Oral Evidence’ on 2nd May 2000 and was ordered to be printed on 15 November 2000. As will clearly be shown later in the manual, the House of Lords Inquiry in no way adequately undertook a thorough review of the contaminated air issue. The House of Lords Inquiry certainly went to great effort to conclude the complete opposite view to what the significantly more detailed Australian Senate Inquiry concluded in relationship to contaminated air; in that there was nothing to be worried about. It would appear that the Government and any interested parties had, through the Lords, achieved their objective for the aviation industry as a whole, of business as usual. This is not surprising given that aviation is one third of UK exports.
Another major contaminated air event occurred on 5 November 2000. This particular event occurred in British airspace on a UK registered BAe 146 and was most likely one of the reasons, along with the strong conclusions of the recently completed Australian Senate Inquiry, that the UK initial BAe 146 certifying Regulatory Authority, the CAA finally took some action. This was known as the ‘Birmingham G-JEAK’ incident in November 2000. [62] As this serious incident involving both pilots was over British airspace it would appear that the UK Air Accidents Investigation Branch (AAIB) and the UK Civil Aviation Authority finally had to act. They had to act especially as the manufacturer of the aircraft was a British based company in the way of British Aerospace and the number of BAe 146 incidents was increasing. The G-JEAK incident is discussed in Chapter 10. It had been the UK Civil Aviation Authority which had issued the BAe 146 its original Certificate of Airworthiness in 1983. Their response as outlined below may have a UK theme and refer to a UK jet aircraft in the guise of the BAe 146 but the arguments and debate apply globally and to all aircraft manufacturers, whether they be Boeing, Airbus or Embraer in the context of contaminated air. This is because the aviation industry is very much a global business which has to date had a global denial of contaminated air publicly.
Aviation activities come under the remit of aviation regulators. The biggest regulator in the world by a long way is the US Federal Aviation Administration (FAA). After the FAA, the UK Civil Aviation Authority (until the birth of the European Aviation Safety Agency (EASA)), used to be one of the main aviation regulators. Most national regulators have looked to the US FAA or to regulators like the CAA, to provide guidance when needed, and in 2000 guidance was being called for on contaminated air events. The reason why many smaller regulators look to the FAA, CAA or others is also because they have far larger resources and expertise than regulators in many countries. The US FAA’s budget for Fiscal Year 2005 was $13.6 billion. [63] Compare that to the total resourcing to be received by the Australian Civil Aviation Safety Authority in 2004-05 of AU$114.7m (approximately US$ 86 million), [64] and it can be seen why aviation regulations drawn up by the FAA called the US Federal Aviation Regulations or ‘FARS’ are adopted by most nations rather than reinvent the wheel. However, the European Union did just this by introducing via the Joint Aviation Authorities (JAA), its own regulations, the Joint Airworthiness Regulations (JARs), which were in any case very similar to the US FARs.
Flight Safety Aspects of Contaminated Air
Reporting Contaminated Air Events with Samples of Known Events
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FODCOM (Flight Operations Department Communication) number 17/2000
FODCOM (Flight Operations Department Communication) number 14/2001 and 21/2002
Aviation Regulators Misinterpret Main Ventilation Airworthiness / Safety Standard
References
14. Civil Aviation Safety Authority (1999-2000) Hansard Evidence by CASA to the Australian Senate inquiry into air safety (1999–2000) BAe 146 cabin air quality. Parliament of Australia, Canberra.
17. British Aerospace (2000) Hansard Evidence by British Aerospace to the Australian Senate inquiry into air safety (1999–2000) BAe 146 cabin air quality. Parliament of Australia, Canberra.
22. Montgomery MR, Wier GT, Zieve FJ, Anders MW (1977) Human intoxication following inhalation exposure to synthetic jet lubricating oil. Clinical Toxicology 11:423–426.
24. ATSB (1999) Occurrence brief 199702276, BAe 146, VH NJF, Fumes in cabin.
38. BAe (2000) BAe 146 Manufacturer’s Operations Manual: Notice to Aircrew, Operational Notice: No OP 16 And 43 (Issue 1). British Aerospace Systems, Hatfield.
52. British Aerospace (1999) submission by British Aerospace to the Australian Senate inquiry into air safety (1999- 2000) BAe 146 cabin air quality. Parliament of Australia, Canberra.
59. SHK (1999) Report RL 2001:41e: Incident onboard aircraft SE-DRE during flight between Stockholm and Malmö, M County, Sweden, on 12 November 1999. Swedish Statens Haverkommission (Swedish Board of Accident Investigation), Stockholm.
60. Senate of Australia (2000) Air Safety and Cabin Air Quality in the BAe 146 Aircraft. Senate Rural and Regional Affairs and Transport References Committee, Final report. Parliament of Australia, Canberra.
61. House of Lords, Select Committee on Science & Technology Report. Air Travel & Health, 1999-2000.
62. DOT AAIB (2004) Aircraft accident report no 1/2004 (EW/C2000/11/4) BAe 146 G-JEAK, 1/2004. UK Department of Transport, Aircraft Air Accidents Investigation Branch, London.
63. Available at: http://www.ainonline.com/issues/01_05/01_05_faabudget_10.html.
64. Available at: http://www.dotars.gov.au/dept/budget/0405/d1.aspx.
