Contaminated Aircraft Air
Flight Crew and FODCOM

Source: Aviation Contaminated Air Reference Manual

FODCOM number 14/2001 © 10th April 2008
by Susan Michaelis

Whilst the UK AAIB investigation into the 5 November 2000 incident on G-JEAK continued, the Swedish Statens Haverikommission (SHK) Board of Accident Investigation made its findings on the incident that occurred on 12 November 1999 to a Swedish registered BAe 146 known as the ‘Malmo Incident.’ The Malmo incident findings were publicly released in late 2001. The Swedish findings, combined with realisation that the AOM were not having the desired effect, should have prompted the UK Civil Aviation Authority to undertake a wide scale educational program. Instead, they decided to issue another FODCOM, which was issued by Captain D J Chapman, Head of the UK CAA Flight Operations Department on 24 August 2001 as FODCOM 14/2001. FODCOM 14/2001 was published as a reminder and to expand on the instructions previously given. The relevant extracts of FODCOM 14/2001 are shown below:

FODCOM number 14/2001

1 AAIB RECOMMENDATIONS FOLLOWING TWO SERIOUS INCIDENTS INVOLVING BRITISH REGISTERED AIRCRAFT UNDERTAKING PUBLIC TRANSPORT FLIGHTS: ONE RELATING TO STROBE LIGHTS, THE OTHER RELATING TO OXYGEN MASKS SELECTED TO 100%

1.3 Oxygen Masks

1.3.1 The second incident involved an aircraft in which two passengers noticed an ‘oily petrol’ smell. In addition, a positioning company cabin crew member had also reported a similar smell.

1.3.2 The aircraft commander asked the senior cabin attendant to go to the rear of the passenger cabin to check the situation. She did so and reported that she could detect nothing unusual. The commander then instructed her to advise him if there were any further indications.

1.3.3 However, later in the flight, both pilots began to feel ill. The commander noticed that the first officer’s face was white and that his pupils appeared highly dilated.

1.3.4 The commander took the handling duties, instructed the first officer to put on his oxygen mask and called the senior cabin attendant to the flight deck. The commander instructed her to check the flight deck regularly during the descent and approach. Thereafter, the first officer took no part in the conduct of the flight although he was able to nod in response to the commander’s questions.

1.3.5 By this stage, the aircraft was at FL70 (7000 feet) and positioning for an ILS approach. Although the commander began feeling progressively worse, he was able to continue the approach and landing.

1.3.6 Following their investigation the AAIB made a number of recommendations including the following: The Civil Aviation Authority should consider issuing additional advice to the crews of jet transport aircraft on the best operational practice when there is a suspicion of flight deck or cabin air contamination. The advice should include the necessity for all flight crew to use oxygen masks selected to 100% and the importance of cabin crew taking an active part in monitoring the flight crew in such circumstances.

1.3.7 FODCOM 17/2000, dated 28 December 2000, contains advice on incapacitation procedures. Operators are further reminded that Operations Manual procedures should contain detailed instructions to crews on such procedures. These should at least include the necessity to use oxygen masks at 100% whenever contamination is present or suspected and the need to establish communications by the appropriate switch selections. Additionally, cabin crew procedures should include monitoring of the flight deck. However, this should not be to the detriment of other emergency procedures such as dealing with cabin smoke or fires, especially where only one cabin crew member is carried.

1.3.8 Operators should also ensure that incapacitation procedures are regularly practised during recurrent training and that case based studies are discussed at joint flight deck/cabin crews safety training.

FODCOM 14/2001 came out but still the incidents continued WITH increasing frequency as will be seen in Chapter 12. The request in 1.3.8 for case based studies relating to incapacitation to be discussed at joint flight deck/cabin crews safety training never occurred. Additionally, there is an emphasis on incapacitations, while it is any form of impairment due to suspected contaminated air right through to incapacitation that is important.


FODCOM number 21/2002

The UK Civil Aviation Authority then issued another FODCOM. This was again done by Captain D J CHAPMAN, Head of the UK CAA Flight Operations Department and was issued on 29 August 2002. This was the CAA's third communication on the issue of contaminated air and was numbered FODCOM 21/2002. FODCOM 21/2002 went into more detail, made some good admissions but also included some parts which were very misleading and inaccurate as will be shown later. The relevant extracts of FODCOM 21/2002 not previously highlighted in the first two FODCOMS are shown below:

FODCOM number 21/2002

1 UK PUBLIC TRANSPORT SMOKE/FUMES OCCURRENCES

1.1 Introduction

1.1.1 The rise in the number of reported smoke/fumes events on UK Public Transport aircraft is viewed by the Civil Aviation Authority (CAA) as a potentially serious issue. This FODCOM looks at these events in more detail. Four aircraft types noted to have a higher than normal history of smoke/fumes events were selected for comparison. Only UK Public Transport reported events have been examined.

1.2 History

1.2.1 Between 1990 and 2001, there were 263 reported smoke/fumes events on the four selected aircraft types. Approximately 25% of these occurrences resulted in the crew or passengers suffering some degree of physical discomfort such as nausea, sore throats and light-headedness. On rare occasions, and only on two aircraft types, flight crew have been incapacitated to a greater or lesser degree.

1.2.2 For each of the four aircraft types there have been some aircraft that have reported more than one smoke/fumes event in the 12 year period studied. For example, there were 113 events recorded by 65 aircraft of the same type with 30 aircraft reporting two or more events. The maximum number of events recorded by individual aircraft in the time period studied was five. There are several cases of an individual aircraft reporting two or more events in a relatively short time period (e.g. a particular aircraft that reported three events in eight weeks) perhaps indicating that the causes of these events are difficult to identify.

1.2.3 The rate of reported events on all four aircraft types has been increasing in recent years.

1.3 Actions Taken, Ongoing and Planned

1.3.4 With respect to another of the aircraft types:

a) The CAA has prompted a series of meetings between an affected operator, the aircraft manufacturer and the engine manufacturer to discuss air quality.

b) The evidence available to date indicates that only one operator of this aircraft type is suffering this phenomenon and then almost exclusively to aircraft powered by one particular model of engine. A team of all parties has defined an enhanced standard of engine rebuild practices to reduce incidence of oil leakage to the cabin bleed. This is now required for all relevant engine shop visits. In addition, revised oil filling procedures are to be introduced and the manufacturer is active in defining the specific troubleshooting procedures to follow after an event. The operator has instructed the immediate donning of oxygen masks and developed its own enhanced troubleshooting techniques for the interim.

1.3.5 The actions taken and planned are considered reasonable for the interim, commensurate with the risk. The probability of future events is being minimised by the likely source being addressed (oil leakage) and by the severity of the effect at the flight deck being reduced (donning masks). Nevertheless, the CAA will continue to encourage the manufacturer for modifications at the aircraft level to eliminate the threat.

1.3.6 The actions taken by the CAA and industry as described above, appear to have made an impact on the rates of the reported high risk smoke/fume events. This is under constant review.

1.3.7 To try to better understand the phenomenon, the CAA is sponsoring research activity that investigates contamination products from engine oil that could represent a hazard to flight deck crew. The purpose is to make a general assessment of the toxic potential of the components and thermal degradation products of a synthetic ester gas turbine lubricant and contamination within the Environmental Control System. This work complements type specific investigations being conducted by the manufacturers. This data is being analysed to try to identify any toxicological links with the symptoms being reported.

1.3.8 The problem of smoke/fumes on UK Public Transport aircraft is now one of the subjects contained in the CAA Safety Regulation Group (SRG) Safety Intervention Programme and is detailed in the SRG Business Plan under the title of Hazardous Contamination of Flight Deck Cabin Air. Work is already well advanced on this subject and one task under this initiative involves a review of the service history for all UK registered large aeroplane types to identify the need for further continued airworthiness actions. In addition, the CAA is to support an FAA/JAA/Industry working group that is tasked to investigate this issue within its broader review of the design requirements related to the cabin environment.

1.3.9 Although the exact cause of crew incapacitation is not yet known, the most probable source is oil leaking from the engines or APU and contaminating the air supply to the cabin and cockpit through the air conditioning system. CAA specialists believe that reducing occurrences of oil contamination will also reduce the risk of flight crew incapacitation. Nevertheless, investigations continue and further mandatory actions will be taken if found necessary.

1.4 Summary

1.4.1 For reasons not fully understood there has been an increase in the number of events reported to the CAA during which aircraft occupants have been exposed to fumes and/or smoke. Advice to flight crew on how to deal with the immediate risks was given in FODCOMs 17/2000 and 14/2001. Research is continuing to identify the causes, however these are proving to be elusive.

1.4.4 The potential for a smoke/fumes event to adversely affect the subsequent operating effectiveness of the flight or cabin crew must be considered. In order to ensure that, as far as possible, the operating effectiveness of the crew is not reduced, the CAA recommends that the operator should take the following actions.

1.5 Further Recommendation

1.5.1 Operators should ensure that flight crews are aware that the first action in the event of smoke or fumes in the flight deck should be for the flight crew to don oxygen masks and establish communications.

1.5.2 Operators should ensure that flight and cabin crew are advised as to the post-flight actions required following a smoke/fumes incident. These actions should include:

a) A Commander’s review of the in-flight incident. This should include consultation with the flight and cabin crew;

b) A determination as to whether any crew member felt unwell, or whether their performance was adversely affected; and

c) The requirement for a crew member who felt unwell, or felt their performance was affected, not to operate as a member of the crew until he/she has been assessed as fit by a medical practitioner and the crew member feels fit to operate.

1.5.3 The instructions to flight and cabin crew should be detailed in the Operations Manual.

The UK Civil Aviation Authority in FODCOM 21/2002 state in 1.2.1 that, ‘there were 263 reported smoke/fumes events on the four selected aircraft types.’ This comment is misleading the public and crews because the significant issue of under reporting is not mentioned anywhere in the FODCOMs and nor did they or have they, taken any steps to address the significant under reporting problem as will be shown in Chapter 12. Although misinformation is investigated fully later in this reference manual, the CAA mislead on at least three occasions in FODCOM 21/2002.

In 1.2.1 they state, ‘On rare occasions, and only on two aircraft types, flight crew have been incapacitated to a greater or lesser degree.’ These facts are incorrect and what the CAA forget to mention is that any crew member being exposed to contaminated can suffer some form of impairment or adverse effects as crews are being exposed to toxic fumes as acknowledged by the oil manufacturers themselves as well as the chemical databases such as the NTP register for TCP, as will be seen in the following chapters. [76][77] It should be noted that the reporting systems do not require crews to report any or all adverse health effects and thus the true extent of adverse effects on flight safety will never be known. The UK contaminated air database (Appendix 2), while only showing a very small fraction of contaminated air events, clearly shows crews are suffering significant numbers of adverse effects (>35 % of all reported events).

In 1.3.4 a) the UK CAA states, ‘The CAA has prompted a series of meetings between an affected operator, the aircraft manufacturer and the engine manufacturer to discuss air quality.’ This is a reminder to us all that the CAA is 100% funded by the airline industry and hence most likely why neither pilot unions, cabin crew unions or passengers groups were invited to attend. [78][79]

In 1.3.5 the UK CAA states, ‘The actions taken and planned are considered reasonable for the interim, commensurate with the risk. The probability of future events is being minimised by the likely source being addressed (oil leakage) and by the severity of the effect at the flight deck being reduced (donning masks).’ This is completely unacceptable for several reasons. As will be seen in Chapter 12 on the number of events and the under-reporting problem, the number of fume events in the UK has been increasing and the CAA to this date is still refusing to accept that under-reporting is occurring. Additionally, the CAA are only aware of around 50% of the events listed on the UK contaminated event database and refuse to address this issue despite being advised on many occasions that their figures are wrong and the evidence provided to show this is the case. Quite extraordinarily, the CAA has applied the following term to numerous events on their Mandatory Occurrence Reporting (MOR) database, ‘CAA closure: The hazard is acceptable provided the frequency remains low.’ [80] This is grossly negligent given the number of events would not indicate the frequency remains low at all. Additionally, to suggest actions are ‘commensurate’ with the risk when they did not know and still do not know what chemicals and the concentrations of these chemicals people are being exposed during a contaminated air event is also seriously flawed. [81] Contaminated air events in 2005 were at an all time high and are still only a tiny fraction of events occurring. The CAA, as we will soon see, do not see many contaminated air events as safety issues and therefore not their concern. [82] Also, inhalation toxicity testing for chronic neurological effects or immunotoxic effects in those exposed and toxicity testing for heated inhaled pyrolised jet oils had not and has still not been carried out. [83][84]


Flight Safety Aspects of Contaminated Air


References

76. Mobil Jet Oil II MSDS. Australia. 2004: ‘Health Hazards: Product may decompose at elevated temperatures or under fire conditions and give off irritating and/or harmful (carbon monoxide) gases/vapours/fumes. Symptoms from acute exposure to these decomposition products in confined spaces may include headache, nausea, eye, nose, and throat irritation.’

77. BP 2380 MSDS, 2000: ‘Combustion Products. Toxic fumes may be evolved on burning or exposure to heat.’

78. T. Ellwood MP. House of Commons [75742]. 12 Jun 2006 : Column 963W, ‘It has been the policy of successive Governments that the aviation industry should be independently regulated, by the Civil Aviation Authority, and that the costs of regulation should be borne by the industry and not by the taxpayer.’

79. CAA: Email from Anne Wallace, Corporate Affairs. SRG, CAA. 5 August, 2003 to Susan Michaelis. ‘The UK CAA is fairly unique in that it is funded entirely by the industry that it regulates and receives no government finance.’

80. CAA MOR database.

81. Countess of Mar HL Question in the UK House of Lords. Question number: HL 2312. 1 December 2005. ‘There is no requirement for air quality monitoring exercises to be carried out during contaminated air events in aircraft, and there is no record of any such measurements in the public domain. Air quality measurements are normally only made as part of the initial certification of each aircraft type.’

82. Countess of Mar HL. Question in the UK House of Lords. Question number: 2311. 23 November 2005.

83. Tyler MP House of Commons [168647] 27 Apr 2004 : Column 888W.’ ‘The CAA did not consider the presence of other substances and effects on low-level exposure.’

84. BALPA: Letter from T. Loraine to Professor I Rowland, Chairman COT Committee, 3 July 2006: ‘Toxicity testing from heated or pyrolised synthetic jet engine oils has never been done and no exposure standard for synthetic jet engine oils exist.’


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