THE AIRLINE PILOTS FORUM & RESOURCE

Contaminated Air and Aviation Safety

Source: Aviation Contaminated Air Reference Manual

National Bureaus of Air Safety ©	10th April 2008
by Susan Michaelis

In 2006 the UK Department of Transport advised that the UK Air Accidents Investigation Branch (AAIB) investigates incidents where, ‘safety was impaired.’ [110] In fact a response in the House of Lords advised that the AAIB will conduct an investigation if it decides that an incident, ‘could have been a significant or serious flight safety incident.’ [111] A further response given in the UK House of Lords indicated that in 10 years to 2006, the AAIB had investigated 23 contaminated air incidents. The International Civil Aviation Organization (ICAO) lists a serious incident including those events requiring emergency use of oxygen by the flight crew, flight crew incapacitation in flight and smoke in the passenger compartment. [112] While taking this definition into account and reviewing the UK contaminated air events database, it is clearly obvious that there are far more than ‘23’ contaminated air events that fall into the ‘significant or serious flight safety incident’ category. Thus it can be concluded that the AAIB is also failing to view contaminated air events with the seriousness they warrant. After all the Australian ATSB advised in its report regarding a BAe 146 incident in 1997 that, ‘The introduction of fumes and odours into the cabin environment following an engine defect constitutes a possible safety deficiency.’ [24] The definition of a safety deficiency under Australian law is listed as, ‘any situation related to aviation that can reasonably be regarded as having the potential to affect adversely the safety of aviation.’ [113] Clearly this is now shown to be the case and if the reporting systems back then had been collated and utilized as required, this would have clearly been the case then.

Failure to Act

By taking the decision not to act on the numerous contaminated air reports or the reported and acknowledged medical effects of exposure to contaminated air that have been reported to the aviation industry for over 40 years, the airline industry has been seriously negligent. Whilst much of the above discussion may focus on pilots and cabin crew, needless to say most passengers on these contaminated air event flights are told nothing. Neither checklists or company operating manuals offer any instruction to inform the passengers. Crews never tell passengers about the possible medical effects from exposure to smoke, fire or contaminated air. Even in the more significant events crews are not being instructed to tell passengers by their employers. This failure to tell passengers was raised in the UK House of Lords. The UK Government stated however in 2004 that, ‘Flight crew are not professionally qualified to verify the cause of air contamination or identify what chemicals if any, passengers may have been exposed to. The captain has discretion to inform passengers of an event.’ [109] Not only have passengers not been informed of such events occurring, no passenger or their doctors have ever been contacted after an event and asked how they are feeling a certain amount of time after an event. Why not?

• Emergency Checklists and Initial Crew Responses

• Defect Reporting

• Reporting Contaminated Air Events with Samples of Known Events

• Aviation Industry Could Have Acted

• Definition of Safety

• FODCOM (Flight Operations Department Communication) number 17/2000

• All Operators Message Ref 00/030V and Ref 01/004V

• Service Bulletin ISB 21-150

• Airworthiness Directive AD 002-03-2001

• When Change was Needed it did Not Occur

• FODCOM (Flight Operations Department Communication) number 14/2001 and 21/2002

• Service Bulletin 21-156

• Airworthiness Directive AD 003-10-2002

• US Airworthiness Directives

• Checklist Ambiguity Boeing and Airbus

• Cabin Crew and Exception to The Complacency Rule

• Are All Contaminated Air Events Safety Issues?

• CAA View of its Safety Responsibilities is Wrong

• Aviation Regulators Misinterpret Main Ventilation Airworthiness / Safety Standard

• Number of Cases of Crew Impairment

• Oxygen is Rarely Being Used

• You are reading >> National Bureaus of Air Safety

• So Where Are We Today?

References

24. ATSB (1999) Occurrence brief 199702276, BAe 146, VH NJF, Fumes in cabin.

109. UK House of Commons written question. Tyler P. MP [[202745], 7 December, 2004.

110. Department of Transport. Letter from Gillian Merron MP, Parliamentary Under Secretary of State to J. Maples MP 22 June 2006.

111. UK House of Lords written question. Countess of Mar. [HL2316] 23 November 2005.

112. International Civil Aviation Organization (ICAO) Annex 13. Aircraft Accident & Incident Investigation. July 2001.

113. Australian Air Navigation Act 1920 S 19AD.