Contaminated Aircraft Air and Flight Safety
Source: Aviation Contaminated Air Reference Manual
Defect Reporting © 10th April 2008 by Susan Michaelis After every flight airlines pilots are required by law to report all defects that became apparent during the flight they have just operated. [30] These can vary from system malfunctions such as a fuel pump failure to failed light bulbs, but everything should be reported. These technical aircraft failures or malfunctions are recorded in the aircraft technical log or sometimes called the aircraft maintenance log, and the captain will sign this book at the end of the flight; such is the legal importance of this book. The maintenance log is a book where pilots (or sometimes only the Captain) enters information such as the total flight time for each flight, fuel load before and after the flight, any technical defects that became apparent to the crew on that flight, oil levels etc. This maintenance log will also have details of all maintenance actions and routine servicing ever carried out to the aircraft. The maintenance log is the history of the life of the aircraft and the aircraft cannot depart without it.
Crews should report contaminated air events in the aircraft technical log as well, as contaminated air is a defect as will be seen in Chapter 15. This is important as all defects should be recorded and dealt with by engineering to ensure the aircraft remains air worthy. If the aircraft filled with smoke most crews would report this as a defect but other contaminated air events where there is no smoke - the majority of all contaminated air events - these are usually not reported, as will be seen in Chapter 12 which covers underreporting. Most crews take the attitude of why report a defect they have not been educated properly about, a defect which frequently does not have a checklist and a problem which is not acknowledged as a health issue by the industry they work for. This means the problem does not get fixed and crews become complacent and see contaminated air as normal. So normal that it even became a joke. [4] Cabin crew are reliant on the pilots to report defects on their behalf, something which, if pilots themselves are not reporting, isn’t very likely to happen.
A clear example of the misinformation that allows the failure to report contaminated air events to the authorities and consequently the failure to fully understand the flight safety implications can be seen in the 2006 UK Committee of Toxicity review. This will be reviewed in detail in Chapter 25 in the UK COT chapter; however, in a nutshell, the committee appears to have been advised by the CAA and the airlines that the reporting of fume events is not mandatory. [31] This position was not corrected by the UK pilot union BALPA. The statements allowing this misinformation to continue include but are not limited to: fume reports not required to be recorded in the aircraft tech log; Air Safety Reports and Mandatory Occurrence Reports not required for all fume / contaminated air events, and airlines are entitled to use discretion as to when fume events are reported to the regulator. All of the above statements are contrary to the actual regulations regarding reporting as can be seen in Chapter 15 and, consequently, the full safety implications are very much ignored in most cases of contaminated air.
In the past, when crews on the rare occasion did report contaminated air events to the company engineers they were frequently told it was not a flight safety issue and / or to report further. [4][32][33][34] The airline industry frequently took a typical business as usual attitude as aircraft that are not flying are not making money. Faced with a complete lack of interest from the aviation industry, crews just got on with the job, just like those who worked with asbestos or in other since acknowledged hazardous workplaces. These may seem like harsh words but this is a scandal of immense proportion because whilst this has all been going on, not only has flight safety been put at risk, millions of passengers worldwide have been exposed to contaminated air. Most passengers don’t know they have been exposed as most of them have never been told and therefore they have not been able to get the appropriate medical attention they deserve. [35]
So where do we get all our data from regarding incidents and their impact on flight safety? In view of the massive under reporting that is occurring the data available is estimated to be less than 4% of the real picture. [36] In fact, there is evidence supporting the fact that on some aircraft types contaminated air events are seen as almost normal [4][37] and a feature of the design of engine oils seals. [38] This lack of reporting which will be covered in greater detail in Chapter 12, was even acknowledged by the Swedish Statens Haverikommission (SHK) Board of Accident Investigation which called for the setting up of an international database of events in a 2001 to record all contaminated air incidents: [39]
‘... that an international database is established with factual information from flights where suspicion of polluted cabin air exists (RL 2001:41e R3).’
This extremely sensible recommendation has yet to occur. This would not be a difficult task today with the advanced computer data storage techniques; however there has clearly not been a genuine aviation industry desire to make this happen. Although contaminated air incident data is not collated as the Swedish recommended and is under reported, there is plenty of data to show that this is a serious health and flight safety matter. Data we have sourced comes from the wide selection of ways available to those crews who choose to report contaminated air problems.
Flight Safety Aspects of Contaminated Air
You are reading >> Defect Reporting
Reporting Contaminated Air Events with Samples of Known Events
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
4. AOPIS (2003) Aircraft Air Contamination: An Ongoing Health And Safety Issue, Documentary. Aviation Organophosphate Information Site. Available At: www.aopis.org.
30. Civil Aviation regulation 1988 (Australia) CAR 248 – Reporting of Defects, Joint Aviation Regulations (Europe & UK) JAR-OPS 1.420 - Occurrence Reporting.
31. COT: Committee On Toxicity Of Chemicals In Food Consumer Products And The Environment (Cot). Update Discussion Paper (December 2006) On The Cabin Air Environment, Ill-Health In Aircraft Crews And The Possible Relationship To Smoke/Fume Events In Aircraft. Tox/2006/39.
32. ATSB (1999) Occurrence brief 199702276, BAe 146, VH NJF, fumes in cabin from oil leak in APU. Australian Transport Safety Bureau, Canberra, 1999. Available at: http://www.atsb.gov.au/aviation/occurs/occurs_detail.cfm?ID=256, ‘After boarding the flight in Sydney, the supernumerary pilot had examined the aircraft maintenance release and noted a deferred defect concerning oil residue at the number two air conditioning pack inlet, resulting from an oil leak from the number four engine. This maintenance release entry was dated 17 June 1997. Maintenance trouble-shooting had isolated the problem to a failing oil seal within the number four engine. The aircraft had been cleared for further flight without any operational restrictions being noted, and the defect was listed for rectification at company convenience.’
33. Pavlinovich N (2003) Witness statement to Australian Industrial Relations Commission. U2002/6475 N. Industrial Relations Commission, Perth. ‘It is common for contamination defects in the aircraft maintenance log book to be entered with the term ‘NSOF’ thereby allowing no immediate action to be taken and the aircraft to continue flying. This term means ‘Not Safety of Flight’. The defect will generally only remain shortly until another crew member enters that they cannot detect the smell.’
34. UK (2006) Contaminated Air Events Database (2006). e.g. 9 November 2002. B757 Fumes. Engineering requested 'report further'. G-BIKT, 10 November 2002 (EW/G2002/11/10) ‘A strong smell of oil entered the flight deck. The crew donned oxygen masks, made a PAN call, and carried out the smoke clearance drill from the quick reference handbook… troubleshooting revealed the source of contaminated air to be the left engine, which was replaced.’
35. Comments made by Dr JC Balouet in the documentary entitled: Contaminated Air: An Ongoing Health and Safety Issue. Produced by www.aopis.org in 2004.
36. Michaelis, S. (2003) A survey of health symptoms in BALPA Boeing 757 pilots. J Occup Health Safety, Australia and New Zealand 19:253–261.
37. Winder, C., Michaelis, S. (2005). 'Aircraft Air Quality Malfunction Incidents: Causation, Regulatory, Reporting and Rates'. Air Quality in airplane cabins and similar enclosed spaces -The Handbook of Environmental Chemistry - Publisher: Springer-Verlag GmbH. August 2005.
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.
39. Incident onboard aircraft SE-DRE during flight between Stockholm and Malmö, M county, Sweden, on 12 November 1999. Report RL 2001:41e. ISSN 1400-5719.
