This text has been translated by the Aerotoxic Association from a blog in German written by Andreas Tittelbach, Lufthansa CityLine Avro captain who lost his health and his job because of contaminated cabin air.
Part 1: Casting off (21 January 2010)
Part 2: The reason for the camels (21 January 2010)
Part 3: Silence is golden (1 February 2009)
Part 4: Better safe than sorry (8 March 2010)
Part 5: Fire services (8 March 2010)
Part 6: Flight LH 4920 (2 April 2010)
Part 7: On the building site of truth (27 April 2010)
Documentaries featuring the author
Note from the author
When I was at school it was undecided whether I should become a pirate or a pilot, but later I was chosen for pilot training at Lufthansa, and for a long time I flew throughout Europe for Lufthansa CityLine. However, in these years the experience has taught me that characteristics which make a pirate's life possible such as ruthlessness, stupidity and cynicism also lend themselves to some careers in aviation.
Casting off
A few days ago I finally took my pilot bag down to the basement. I’ve known for a year that I won’t need it again. It was still sitting right next to my table ready for duty equipped with logbook, sunglasses, world map and other more or less necessary items I kept in there over my years as an airline captain. Now it’s placed right next to other pieces of my past that I couldn’t part with, packed in cardboard boxes.
Goodbye takes time, and my flight kit was the last visible sign of my flying career, my job that I loved and that ruled my life for years.
Since the aviation doctor took away my licence to fly on the 19th November 2008, I know that I will never fly a plane again and that I have to look for other goals and content in my life.
But like a cruise ship has to cast off its ropes before it can go on a journey across the sea, the old things in life have to be finished before something new can be born, the past connections have to be cast off. Sometimes it might be enough to put a suitcase away for good, or give something away that’s lost its meaning. But in other cases, goodbyes can only happen when things don’t get put away, but laid out on the table and spoken about openly.
My employer Lufthansa CityLine and I frequently had different points of view about how to deal with technical defects and it didn’t work out to come together on these issues over my years working for them. Possibly, it even got worse over time, and like with most conflicts, when both sides take a more radical position it makes the debate more lively. Now I no longer fly and the business of Lufthansa CityLine is no longer mine. But one issue like no other has influenced my relationship with Lufthansa CityLine, and it has actually cost me my health and career.
Since 1994 I flew the Avro RJ85 aircraft, a modern version of the BAe146 and over these years I wrote many reports about contaminated cabin air caused by oil fumes. These fumes get into the cabin from the engines via the air conditioning system, and get inhaled by crew and passengers. Just like other colleagues, I reported the adverse health effects experienced during and after being exposed to oil fumes. Lufthansa CityLine knows that the oil fumes contain toxic compounds, but in my opinion they still don’t treat the problem with the necessary importance. Therefore, this cannot be the last said on the matter.
Original German version ‘Leinen los’, written 29 November 2009
The reason for the camels
In 1994 the first Avro RJ85s were added to the Lufthansa CityLine fleet and I was proud to be one of the first to fly the aircraft. Because our training captains, who usually introduce the other captains to a new aircraft, had to be trained on the Avros as well, the manufacturer British Aerospace sent their own training captains to Lufthansa CityLine, who also introduced me to the new aircraft type.
These older, very experienced captains were pretty much what you call "old sea dogs" in naval talk. And because they were so experienced and had flown so many thousands of flying hours on the BAe 146, of which the Avro is a modern version, oil fumes were mentioned soon enough.
One of the not so nice aspects of the BAe146 and the Avro is that the quality of the air coming into the cabin and cockpit from the air conditioning isn’t always what you would consider breathing air. To understand that aspect, you would have to know that on most modern passenger aircrafts, the air is drawn from the engines.
Very simply put, a jet engine compresses part of the air entering the engine, mixes it with fuel, burns that mixture and blows it out the other end with somewhat more force. Because that works best at high altitudes, aircraft fly at altitudes where density and temperature of the outside air is not a very comfortable breathing environment for human beings. To keep people onboard an aircraft alive and kicking, the aircraft cabin is pressurised so that density and pressure inside the cabin are much higher than outside the aircraft. Ideally the flight attendants can even set the temperature for your comfort.
To get the air pressure and temperature inside the cabin to a comfortable level, you need warm, dense air. A way to make that happen would be to take the thin, cold air from outside, pressurise and heat it and supply it to the cabin. That’s the way it was done at the beginning of commercial air travel. At some stage though, someone noticed that there was already pressurised and heated air - in the engines. So it would be much more economic to just take the hot air from the engines instead of going through all that trouble pressurising and heating the outside air. There is nothing wrong in using this "bleed air" as long as the air arriving in the cockpit and cabin is nothing but clean air. Whether that is what actually happens depends on the seals in the engine where the air is bled off, and how well they work (they should work well enough to keep oil and hydraulic fluids from entering the air stream, and that is also the case for APU air which provides the cabin/cockpit with "fresh" air on ground).
And that’s what brings us back to the BAe 146 and the Avro. Neither aircraft type differs much in the way that air is provided to the crew and passengers, and both are well-known for letting dangerous fumes and gases from the engines and APU into the cabin.
The manufacturer has tried for over 20 years to get the air on board its aircraft clear of bad smells and toxic contaminants with different techniques like technical changes in the engine air supply and air conditioning system, but with very limited success. These aircraft types are the ones which show up by far the most in reports from around concerning oil fumes and contaminated cabin air. Hearings in the UK and Australian Parliaments and a number of international conferences covered this issue in the past few years, always with the focus on the BAe 146 and its siblings. The main reason is probably the special construction of the engines, the failing of its seals and the oil it uses. Over the past 20 years British Aerospace has issued a lot of documents to the airlines using their aircraft, in order to get this problem under control. These include maintenance manuals for the engines, seals, air supply and air conditioning, as well as procedures in the event of yet another cabin air contamination. With typical British understatement, BAe calls these procedures: "Continuing interest in the subject of cabin air quality (SIL 21-45 of November 2000)".
At Lufthansa CityLine these manuals/procedures weren’t adopted completely, they thought they knew better how much attention to give to the fact that humans inhale substances onboard Lufthansa aircraft that are scientifically proven to be highly toxic.
I am no scientist, just a pilot. But even I, after flying some time on the Avro, found that the many fume events have to be considered a serious health hazard instead of just a smell nuisance, as is the case of my employer.
Because the problem has been reduced to something that only reduces the comfort onboard a little, it didn’t otherwise merit much attention. Aircraft that obviously had an oil-contaminated air supply just kept on flying instead of getting maintenance and all the time-consuming and expensive investigations and tests the manufacturer suggested. People flying onboard these aircraft were knowingly put at risk.
Now, Lufthansa CityLine is obviously a for-profit business and not a welfare institution, but I believe that a business enterprise should still feel obliged to protect the health of its employees and passengers. But because Lufthansa CityLine chose the easier and cheaper way in the matter of oil fumes inside the cabin, it put profits above crew and passenger health.
For many years I have talked to base captains, flight managers, safety pilots and chief pilots, but for the time I was employed, nothing changed. Only one thing maybe: that the messenger was seen as the problem, not the message.
That made me very tired. I experienced the effects of oil fumes myself, and doing my job became more and more a series of demands and threats. To fight these threats got very exhausting. At the same time my health deteriorated over the years, without being able to find a clear reason.
Now I get new medical reports every month that show neurological damage as usually found in people who have been exposed to organophosphates like TCP. This exact TCP is one of the most toxic compounds in the oil that Lufthansa CityLine uses for its engines.
And they still claim today that it’s only a smell nuisance.
I think it’s not right and it cannot stay that way. In the interest of everyone who still gets on these aircraft, something has to change at Lufthansa CityLine. Maybe I can help my employer to bring about this change. Like it’s hard for some people to change their ways and to re-think, the same is true for companies and its management. To find new objectives it helps to look back at past mistakes, and with that I can help for sure. If the retrospective shows all the wrongs, it should be easier to make the right decisions for the future.
Oh yes, the camels:
Ruthless economic decisions at Lufthansa CityLine have cost me my health and career. No one can give that back to me. But if I can help that no one has to get on a Lufthansa aircraft and breathe toxic gases ever again, it would relieve my mind and give me some sense of satisfaction. Just as one hundred camels would for someone who is the target of a cowardly murder in Arabic countries.
Original German version ‘Vom Sinn der Kamele’, written 2 December 2009
Silence is golden
Let's suppose for a moment you just bought yourself a new car. Shortly after that you receive a letter from the manufacturer stating: “Just to let you know, we found out that the seals in the engine don't work properly, so when you press or release the gas pedal, oil fumes could be released into the air conditioning. At the moment we don't know how harmful these fumes are to your health, so please contact us if you get ill from them. Thank you very much!” Would you keep the car? Me neither.
In January 2001, Lufthansa CityLine received a document from British Aerospace (AOM Ref 00/030V) that states that under normal operating conditions it is possible that hydraulic fluid and engine oil will regularly get into the air conditioning and contaminate the cabin air. If this happens when the pilots increase or decrease engine power, it’s not even considered a defect.
For the Avro aircraft type, Lufthansa CityLine uses “Mobil Jet Oil II” engine oil. The oil manufacturer Mobil knows that the oil is highly toxic and so does Lufthansa CityLine. Until a few years ago, Mobil put the following warning on its tins:
“Warning! Contains Tricresyl Phosphate. Swallowing this product can cause nervous system disorders including paralysis. Prolonged or repeated breathing of oil mist, or prolonged and repeated skin contact can cause nervous system effects.”
In a Material Safety Data Sheet for Mobil Jet Oil II from 1996, the following information was published:
“NOTE TO PHYSICIANS: This product is not expected to produce adverse effects under normal conditions of use and appropriate personal hygiene. This product contains TCP which can cause symptoms associated with cholinesterase inhibition. TCP may also produce neurotoxicity associated with inhibition of neuropathy target esterase (NTE). Effects of cholinesterase inhibition are expected to occur within hours of exposure, but neurotoxicity related to NTE inhibition may not become evident for several days. Treat appropriately.”
(Under “normal conditions of use” means that a mechanic opens the tin and puts the oil into the engine, just as you would with car engine oil. It doesn't mean that heated engine oil leaks into the air-conditioning, just as British Aerospace said it could during normal flight operations).
The warning on the tins has since been removed, but that doesn't change the toxicity of the product.
Amongst other things Lufthansa CityLine received another information leaflet from British Aerospace in January 2001, Service Information Leaflet 21/45. Over 30 pages BAe explains how Lufthansa CityLine should deal with reports from crews about oil fumes in the aircraft, or if crews are worried in general about the air quality onboard. Part of the SIL 21/45 is a questionnaire that pilots and flight attendants have to fill out, with details like exactly when the air contamination took place and under what circumstances. On the last page of the questionnaire a wide range of health symptoms are listed, which should also be reported when experienced by crews. That list includes many symptoms like sore throat, nausea, headache, fatigue, “moon-walking”, shortness of breath, dizziness and passing out.
Lufthansa CityLine published this questionnaire including the health symptoms as an Engineering Order on the 22nd January 2001 with the following additional information:
“Recent press reports have raised issues concerning cabin air quality on a range of aircraft types including the Avro RJ 85. BAe Systems, the manufacturer of the RJ family is working on a continuous process to improve cabin air quality.
....
In the extremely unlikely event of bad air quality, please fill out the attached "Cabin Air Quality Questionnaire”.
....
Please record all occurrences! Only a complete documentation can lead to an improvement of cabin air quality.”
These incidents were not “Extremely unlikely” in any way. Oil smells more or less belonged on board the Avro aircraft of Lufthansa CityLine. That's why I filed dozens of “extremely unlikely events” of oil smells onboard. Every time I experienced sore throats, headaches, nausea or a fatigue-like feeling, I filled in the survey and sent it via fax to Lufthansa CityLine. Apart from the two serious incidents where I and the other crew members had to go to the hospital suffering severe health effects, when I additionally sent an official accident report.
On 18th January 2002 my flight duty included a return flight from Frankfurt to Kattowitz. On the flight to Kattowitz the co-pilot and I experienced a strong oil smell in the cockpit. We didn’t know at the time how dangerous these oil fumes were - how would we? We knew the smell well enough from everyday flying and our employer spoke only about a “nuisance smell”. So we made our way back from Kattowitz to Frankfurt. At some stage during the cruise we both began to experience adverse health effects. My colleague described the smell in his report as a “strong, irritant scent - highly concentrated during all phases of flight”. We both suffered from nausea, irritated upper airways and headaches. Also both of us acknowledged a sort of fatigue and a loss of concentration. It was night time in the cockpit of a passenger jet, at 28000 feet altitude. When we figured out that our loss of concentration was due to the oil fumes, we both donned our oxygen masks. Only after breathing pure oxygen for a while did we realise how much we were under the influence of these fumes and how they had affected our cognitive ability. As if someone had pulled away a curtain from our eyes, the tunnel vision faded, along with the nausea and we were able to think straight again. We realised what a dangerous situation the oil fumes had put us in. Later we found out that there were two engines leaking a large amount of oil into the air conditioning. That was also the reason why we had stronger symptoms than usual, when you would get away with a simple headache.
The co-pilot and I knew that our symptoms had been caused by the oil fumes, so we went to a hospital after arriving in Frankfurt in order to get appropriate tests done. But the hospital doctors had no idea what to do with these pilots who had inhaled oil fumes, which additional tests to do and what to look for in blood and urine samples. And neither did we.
But we could have had the information, because Lufthansa CityLine had it. But they had kept it concealed.
On page 9 of the SIL 21/45, BAe had notified Lufthansa CityLine in January 2001:
“Crew Medical Tests
BAE SYSTEMS have obtained medical advice about which medical checks should be carried out after an event. Where crew report any impairment, it is recommended that affected crew should be subject to medical examination as quickly as possible after reporting such symptoms to ascertain if the cause can be identified.
In order to reduce the possibility of external variables influencing the results of such examinations, crew movement details between the flight and the medical examination should be recorded.
Appropriate medical tests should include the following:
1. Take blood samples as soon as possible after landing: 10 ml in a lithium heparin pot and 2 ml in an EDTA pot for: a full blood count including haemoglobin, white blood cell count, packed red cell volume and platelets, c-reactive protein, temperature, carbon monoxide haemoglobin and cholinesterase activity in the blood. A clotted venous blood sample (10 to 20 ml) should be frozen at –20 deg C and stored for possible later testing.
2. Take and retain a urine sample, this should be chilled at 4 deg C and stored for possible later testing.
3. Ascertain personal medical history. This should include details of any drugs or medication taken, and details of any previous exposure to potentially toxic substances (e.g. hobbies, previous employment in other types of work or other activities involving exposure to paints or solvents etc.) Perform physical examination including neurological examination.
4. Record accurate and precise details of clinical symptoms: what symptoms were experienced? When during the flight did each symptom become apparent? How long did each symptom last? Was the symptom relieved by the use of oxygen? How were the onset of symptoms related to detected smell/odour? Were the symptoms related to any ECS system switch selections?”
So Lufthansa CityLine had been officially informed by the aircraft manufacturer that after every contaminated air incident the crew should get medically examined as soon as possible, and that blood and urine should be taken and frozen for later testing.
Lufthansa CityLine kept this information to themselves. Why? Was it because they wanted to prevent pilots and flight attendants worrying about their health? Were they concerned that when there were oil smells on board, the crew would really go see a doctor instead of continuing with their job, and that more staff would then be needed? Did they fear that this matter might be taken seriously and the aircraft would spend more time in the hangar than actually transporting passengers and making money?
At any rate, Lufthansa CityLine has showed how much importance they attach to their employees’ health, and the question should be raised how far their responsibility goes towards the passengers who are entrusting their lives to the company.
Original German version ‘Schweigen ist Gold’, written 7 December 2009
Aerotoxic Association note:
Documents referred to in the blog:
BAE Systems All Operator Message: Ref 00/030V
BAE Systems Service Information Leaflet 21-146-RJ-536-1 (direct replacement for SIL 21-45)
Better safe than sorry
If you were following the news at the end of 2009, you would have got the impression that Deutsche Bahn (German Rail) and its subsidiaries were in a sorry state. Every couple of weeks they would take a whole fleet of trains out of service, and they were only allowed back on the tracks after time-consuming maintenance and repairs. This made waste paper of the timetables, annoyed a lot of passengers and cost the respective companies a huge amount of money. But in the end it showed the extent and severity of the defects that were found by the regulatory checks, that the German Federal Rail Authority were acting in accordance with their obligations as a control and supervisory authority, and therefore preventing rail accidents that were a danger to the traveling public.
Germany has also established an authority for air travel: the Luftfahrt-Bundesamt (LBA). You usually only hear about them at the beginning of the holiday season when their employees go out and make checks on aircraft from third world or emerging nations, tell off the airlines concerned and make it all public. If it’s really serious and usually after a few hair-raising incidents or accidents involving the dubious airlines in question, the LBA prohibits them from landing in Germany, political ties permitting.
So all in all we can confidently say that the LBA is a well-meaning friend of the airline industry. If the airlines being overseen were banks, they would be called “system-relevant”.
As a result, you never read in the newspaper that a major German airline has been rapped over the knuckles.
Of course that could just be because everything is wonderful with German aviation and that the friendly but meticulous official inspections by the authorities always show that the conscientious German airlines are complying with all the regulations and how flawlessly everything's running.
It’s also conceivable that excellent political contacts to the Ministry of Transport, personal acquaintances and close links with the regulating authority have lead to some cordial understandings with the result that the LBA have forgotten the old adage, trust is good, but control is better.
Whatever the reason, we simply don’t know.
However, it is very clear when it comes to airline operations, by law any incident must be reported immediately to the appropriate authority, the BFU (German Air Accident Investigation Branch).
All the reportable events are listed in appendix 6 of § 5 of the Luftverkehrsordnung, LuftVO, (German Aviation Regulations). As so many types of events and aircraft technical faults have to be reported, you could say incidents as defined by the LuftVO are part of the everyday operations of an airline. Some of the larger airlines have therefore established their own reporting system, whereby the captain doesn’t report directly to the authority, but instead the airline is responsible for reporting incidents, and makes sure the reports are received by the authority correctly and in a timely manner.
Lufthansa CityLine has also stated in a notice to their pilots that incident reports should be filed internally within the company. The relevant section of the Operations Manual ends with the words: “By following the CLH (Lufthansa CityLine) reporting procedure as shown below, the Commander meets his legal obligation of immediate notification. In addition a written report has to be submitted.” So the company assures us that the captain is fulfilling his legal duty of reporting.
In early 2009 several journalists were becoming aware of the health hazard to passengers and crews caused by oil fumes entering the aircraft cabin. In an interview, a representative of the BFU stated that such events are reportable under § 5 of the LuftVO and would therefore be taken very seriously. At the same time it was made clear that the authority had received very few reports of this kind.
I have personally experienced so many of these fume events at Lufthansa CityLine and reported them in-house, and the fact that the BFU had not got many reports was a surprise to say the least. As a captain I am required by law to report these events and a breach would mean a very large fine. I wanted to make sure Lufthansa CityLine had passed on all my reports, so politely asked my fleet manager if they had actually been sent to the BFU as required by § 5 of the LuftVO, and if I could get copies of them.
Lufthansa CityLine sent its answer via a lawyer stating that: “… our client has, in respect to known reportable incidents, fulfilled their obligation to report them. We see no reason to disclose any more information.”
Following this plausible answer, I didn't think about the matter for a few months until I got invited to a presentation a few weeks ago, where I got to hear again that the BFU had received very few reports from Lufthansa CityLine about oil fumes. In total the number available of reports was less than the sum of the events that I alone had experienced.
I began to worry again that my employer might have forgotten to report some of the incidents. Especially because at that presentation I had heard from a well-informed and credible source that because of the seriousness of the issue and because of the lack of reports, the first pilot would soon be facing a fine.
To finally clarify my reporting obligations as a captain if the air on board gets contaminated, and to avoid a fine, I wrote a short email to the regulator to ask for an explanation.
As I know that many of my colleagues read this blog and have similar doubts about the reporting requirements, it clearly makes sense to publish the whole email correspondence with the BFU here:
From: Andreas Tittelbach
Sent: Wednesday, 25th November 2009 8:49am
To: ""@bfu-web.de
Subject: Cabin Air Contamination
Dear Sir / Madam,
As a captain on the BAe146 / RJ-85 I have had numerous incidents on this aircraft type involving cabin air becoming contaminated with oil fumes from the engines or APU through the air supply system.
In recent years various scientific publications have highlighted the significant health risks for passengers and crew posed by these oil fumes and I know the short- and long-term adverse health effects associated with the inhalation of such oil vapors from my own experience.
In this context I would like you to answer the following questions:
Is the entry of oil fumes from the engines and/or APU into the air supply of an aircraft cabin a reportable incident as defined by §5 of the LuftVO?
If so, who is notifiable?
What are the implications if an incident is not reported?
What are the consequences of a delayed report?
Yours sincerely,
Andreas Tittelbach
I received the following answer:
From: "" @bfu-web.de
Date: 27th November 2009 12:08:21 MEZ
To: "Andreas Tittelbach"
Subject: RE: Cabin Air Contamination
Dear Mr Tittelbach,
Thank you for your email of the 25th November 2009.
I would like to answer your questions as follows:
Re Question 1
Oil fumes entering the cabin from the engines and APU through the air supply system is not a specified event in terms of system design (a malfunction). The FlUUG consider it a malfunction, particularly in connection with toxic TCP concentrations. If, in the context of such an incident, safety-related impairment or incapacitation of crew members take place, it can be classified a serious incident. Basically the BFU makes such classifications, so all incidents with a potential safety risk to flight operations have to be reported to the BFU whenever they could potentially be classified a serious incident.
Re Question 2
§ 5 paragraph 2 states that a serious incident involving a civil aircraft must be reported immediately to the BFU by the aircraft commander. §5b LuftVO "Reporting of safety-related incidents" states in paragraph 1 that the operator or aircraft commander of an arcraft with a MTOW of 5700 kg or more must report to the LBA any incidents which endangered the aircraft, its occupants or third parties, or would have threatened to have done so if no preventative action was taken. Paragraph 2 states that an incident as defined by paragraph 1 could be an operational failure, malfunction or abnormal event with an actual or a potential influence on flight safety. In this context I refer you to the Luftfahrthandbuch Deutschland (German Aeronautical Information Publication) that points out the duty of reporting such incidents under ENR 1.1-49, note 3 as well as section A, point 7; appendix B, point 2, part k); point 3, part c); point 4 and 5.
Re Questions 3 and 4
First of all, late reporting prevents the BFU from further investigation of the incident. The greater the time span between the report and the initiation of the investigation, the more difficult it may be to determine the causal relationships, for example the on-board recording systems may have been overwritten. Failure to report a reportable incident is an offence under § 43 of the LuftVO and can be punishable by a fine: “An offence according to § 58 paragraph 1 No. 10 of the Air Transport Act refers to an intentional or negligent act […] 10. as owner, commander or other crewmember who, contrary to § 5 paragraph 1, 2, 3 or 5, interferes with the operation of an aircraft and does not report it in a timely or correct manner; […]”
If you should have any more questions, please feel free to contact me.
Sincerely,
On behalf of
Bundeststelle für Flugunfalluntersuchungen (BFU)
Hermann-Blenk-Str.16
38108 Braunschweig
Because of these answers, and because I don’t want to be fined, I again reported all the incidents to the BFU that were still available to me, although I assume that all the incidents were reported by Lufthansa CityLine. As my grandmother always says “Better safe than sorry”.
Maybe the BFU’s statement and my grandma’s worldly wisdom will help one or two colleagues find a way to avoid the Cabin Air Contamination problem, the way it should be.
Even so, I have to say that my grandma still doesn’t believe me when I tell her about the oil fumes in the aircraft. Her answer is always: "But this is Lufthansa!"
Original German version ‘Doppelt hält besser’, written 19 December 2009
Fire services
“After landing ... white, slightly unpleasant-smelling smoke came out off the air conditioning... smoke was also visible in the cabin area.”
“After landing, smoke was apparent again.”
“On final approach ... smoke in the rear cabin ... the smoke warning went off ... slight smell in the cockpit ... fire services on standby.”
“Oil smell detected in the cockpit and cabin ... cause of the oil smell a broken engine bearing seal.”
“After take off from XXX we noticed a strong pungent smell in the cockpit ... we diverted to XXX ... On final approach the first officer complained that he had a headache ... the fire services were waiting for us by the side of the runway.”
“After the crew detected an oil smell in the cabin and cockpit, the flight crew declared an emergency. Due to the strong smell, oxygen masks were donned.”
“... incident occurred shortly after take off. The crew detected an oil smell in the cockpit and diverted to the nearest available CLH (Lufthansa CityLine) maintenance base.”
These are typical excerpts from Lufthansa CityLine flight safety department publications, in which crew members have written about flights on which they were exposed to oil fumes. Elsewhere the flight safety department states that: “in 7% of safety-related incidents on the ARJ (Avro) aircraft, crew suffered adverse health effects.”
This is an amazing number, and the alarm bells should be ringing, especially in light of the fact that the oil in question contains a highly potent neurotoxin.
Apart from the long-term health damage that crews and passengers can suffer when exposed to oil fumes, a crew breathing in a neurotoxin is a significant concern for flight safety. Even the aircraft manufacturer itself admits it’s possible that these oil fumes could put a pilot in a drunken-like state, leaving them dizzy, tired, euphoric or tired.
After detecting oil fumes, the first and most important first action is for the pilots to don their oxygen masks. This will provide pure oxygen, protect them from the toxic air and allow them to continue functioning.
Until today, Lufthansa CityLine still can’t decide whether to make the use of oxygen masks mandatory for all incidents involving oil fumes. According to a publication of 19 June 2009 from the flight operations management, “In the event of a fume event, the “Smoke, Fumes or Fire on Flight Deck / Passenger Cabin / Electrical Equipment Bay” procedure should be considered (Memory Item: Don oxygen mask, check 100%)."
But it’s the “considering” that is difficult for a pilot that has been breathing engine oil fumes over a long perios, hence the requirement to don the oxygen mask as the first action the above checklist. Of course this is the only way to be sure he is conscious and remains lucid so he can consider the situation further.
Lufthansa CityLine claims that: “The health and wellbeing of our employees is the highest priority and is very close to our hearts”. Anyway, flight safety is more important than anything, but for some reason, they can’t bring themselves to make the “Smoke, Fumes or Fire on Flight Deck / Passenger Cabin / Electrical Equipment Bay” procedure mandatory for a fume event.
Would it possibly have something to do with the next item on the procedure after donning the oxygen mask, which reads: “Land as soon as possible”, leading to Lufthansa CityLine aircraft declaring emergencies and diverting far more frequently?
I don’t know.
What I do know though, is that EASA is conducting a survey on the subject of Cabin Air Contamination and is accepting submissions about Oil Fume Events until 8 January 2010.
If we want our employers to follow up words with action and to take aircrew and passenger health seriously, we need to keep sending reports to the authorities, otherwise things will carry on as before.
This way to EASA:
Cockpit: http://ec.europa.eu/yourvoice/ipm/forms/dispatch?form=CabinAirFC
Cabin: http://ec.europa.eu/yourvoice/ipm/forms/dispatch?form=CabinAirCC
Aerotoxic Association note: The surveys are now closed
Original German version ‘Feuerwehr’, written 19 December 2009
Flight LH 4920
“TCP is an additive in engine oil and can cause neurological effects if it gets into the air supply. If there is excessive wear of the engine seals, oil residues can get into the cabin air through the air conditioning system and degrade the air quality”.
Armed with this knowledge, the Lufthansa CityLine chief pilot attends a management meeting.
Now one would think that an airline that becomes aware of a significant health risk on their aircraft would pass on this knowledge without hesitation, and that all steps would be taken to ensure that daily operations are carried out without customers and employees being harmed by neurotoxins.
On a cold but beautiful spring evening in Munich some time later, Lufthansa flight LH 4920 to Birmingham, an Avro RJ85, is prepared for departure. After the last passenger has found their seat, the aircraft doors are closed, the engines started, and D-AVRP is on its way to the runway. While taxiing, the pilots perform the necessary system checks, while the flight attendants make an announcement to the passengers about safety procedures on their Lufthansa flight.
After all checks are completed, the captain steers the aircraft onto runway two-six-right, increases the speed of the engines to the calculated take-off power and a short while later LH 4920 lifts off and climbs into the night sky over Munich. At this point the air is supplied from the engines, a certain amount of hot air is bled from the internal air flow, cooled and fed into the passenger cabin.
As the engine power was increased for takeoff and during the climb the captain noticed a strong smell of oil in the aircraft. If the captain had known that this influx of toxic fumes was a significant health hazard, he and his co-pilot would have put on their oxygen masks, turned around and landed safely back in Munich a few minutes later. That would have kept the crew and passengers from harm. Obviously he wasn’t aware of the seriousness of the situation, neither were any other crew members. So they continued the long flight to Birmingham and the passengers continued to breathe the oil mist, even though the chief pilot and managing director knew that the TCP in the oil can have neurological effects if it gets into the cabin air.
The captain of that flight probably didn’t know. However, he did document the cabin air oil contamination in the technical logbook and sent a message to technical operations control informing the engineers about the problem: “STRONG OIL SMELL DURING T/O BLEED ON ENGINE AIR”. He specifically points out that the oil fumes have entered the aircraft cabin from the engine air supply.
What happens now? Will engineers and spares will be sent to Birmingham to repair the aircraft there overnight and to clean the air conditioning system and air supply, as specified by the aircraft manufacturer? Will it at least be taken out of passenger service until it’s repaired and cleaned? No, nothing like that. D-AVRP is parked overnight in Birmingham and sealed, in order that it can transport another crew and some unsuspecting passengers to Munich the next morning, still with contaminated air entering the passenger cabin and cockpit via the engines. The captain in charge in the morning doesn’t see a problem with transporting passengers in an aircraft whose cabin is getting contaminated by engine oil. It appears that he too has not being made party to the information shared by the chief pilot and the management.
The aircraft reaches Munich and finally an engineer is assigned to address the problem. Although the complaint recorded in the technical logbook states that one of the engines is the cause of the contamination, the technician goes to the tail of the aircraft where the APU (Auxiliary Power Unit) is located to diagnose the fault. The APU can also be used to supply air and is often the cause of contamination. The man promptly finds the problem: a defective seal and related oil leak. He determines that the seal must be replaced and declares the APU unserviceable until further notice.
Although it is assumed that the air supply systems have been contaminated by this oil leak, and that the aircraft manufacturer specifies the air conditioning and air ducts should be washed out following these events, this work does not take place.
Although the captain’s complaint from the previous day suggested that oil was getting into the air conditioning via an engine, it is not properly verified whether in fact an engine is the cause of the problem. Instead the aircraft is immediately made available for further service.
Aircraft on the ground cost money and don’t earn. According to Lufthansa CityLine publications no one ever really comes to any harm through oil fumes. So everything is not so bad.
Only when the crew allocated to the next flight don’t accept the aircraft in this state and demand that proper fault-finding is performed do more checks take place. It turns out that one of the engines really does have a defective seal allowing oil into the air supply system. Not until a few days later after a new engine is installed and the soiled air filter replaced is there no more air contamination, for the time being. The captain’s observation on the flight to Birmingham that one of the engines was the source of the oil smell was therefore correct: one of the engines was leaking and allowing oil into the air conditioning.
If the chief pilot and the managing director of Lufthansa CityLine had imparted their knowledge of the dangers of toxic substances in engine oil to their employees with the necessary urgency and given clear instructions of what to do, pilots would have not carried out such flights, aircraft engineers would have carried out the work conscientiously and people aboard the two Lufthansa flights wouldn’t have breathed any toxic oil fumes.
Lufthansa CityLine states the following in front of the industrial tribunal:
“The defendant (Lufthansa CityLine) takes complaints from employees about oil smells in the cockpit very seriously.”
“If (…) a single report of an oil smell is received by the crew, the procedure is as follows: The air filter should be (…) replaced immediately and the whole aircraft checked”
“Detailed troubleshooting is performed following each report (...)”
“If specific complaints are expressed about oil smells, the following procedure will be accomplished: If “Oil smell” has been reported or entered in the technical log by a pilot, the fault will be rectified and tested in accordance with the manufacturer’s requirements before the aircraft is put back into service”.
“I hear the message well but lack Faith's constant trust”. (Goethe)
Original German version ‘Flugnummer LH 4920’, written 23 January 2009
On the building site of truth
Do you know Aunt Törtchen? Aunt Törtchen has a farm. The raven, the little badger and the wild pig want to spend their holidays there. However, the friends and Aunt Törtchen have different ideas about the course of events during their stay. With the raven’s encouragement, they decide to play tricks on Aunt Törtchen and tell her tall stories. Only a killjoy would say that telling stories is the same as lying, explains the raven to his friends. But this is how lying starts. One tall story leads to another, and then the lying begins to get out of hand. In the end everything comes out and Aunt Törtchen learns the truth.
My little daughter really loves this story, mainly because of the increasingly absurd lies the raven and his friends have to come up with. She has grasped that cheating and deception ultimately don’t work, but instead just serves to get everyone in a temper. In the end all the liars are standing there looking stupid and have to apologise.
I don’t know if the Lufthansa CityLine management sometimes read the stories about the little raven, but it seems things are getting tricky for them. The old pretences that everything is going to be just fine and that there’s nothing to worry about don’t hold up any more.
Maybe this is the reason the AVRO fleet manager recently sent a letter to his pilots, in which it was admitted for the first time that there really is a serious problem with the cabin air quality on the AVRO and that oil fumes regularly get into the air that the passengers and crew breathe.
For years there have been attempts to “improve the ongoing air quality problem”, but it has not really been successful. This year further technical modifications are planned with hopes that it will lead to a real improvement. Until then an improvement in the air quality with be attempted with modified flight operating procedures. What’s more, the pilots have received new instructions on how to adjust the engine thrust. Loosely translated they say “Easy on the gas!” According to the explanation given by the fleet manager this is necessary because every time the power is increased rapidly from idle the engine seals don’t seal correctly, with the result that toxic engine oil gets into the air supply system.
For the first time Lufthansa CityLine admits that it’s not the APU but the engines that are the most common cause of air contamination. According to the aircraft manufacturer there is one "point" in the APU which is a likely source of air contamination, whereas on each engine there are four such "possible points”. As each Lufthansa CityLine AVRO has four engines each with four problem areas plus an APU, it follows that an aircraft smelling of oil has seventeen potential points that are the cause of the contamination.
If you know that the engine oil you use is very toxic and that there are these seventeen potential problem areas, you should give every one of them a lot of attention during maintenance. In the event of an oil leak you should look at each of the seventeen points very carefully before the aircraft is put back into service. Apart from the need to clean the air supply system after it has got contaminated, it’s not enough to simply take the APU out of use thereby isolating one of the seventeen “points”, and to then blithely continue flights with the other sixteen “points” in operation. However, in my experience this is routine practice at Lufthansa CityLine.
It has now been admitted that there has been a problem for a long time but in my opinion it is not being dealt with as consistently as the employees and customers would expect. If it were, it would mean that the AVROs wouldn’t be able to fly so often and would therefore earn less money. What goes for the raven is on his holiday on the farm also works for the Lufthansa CityLine management who massage information so everything appears just as we imagine it should be.
Presumably it’s also exactly the reason the fleet manager reminds his pilots that their workplace oxygen masks are available and that they should sometimes think about putting them on if oil fumes come out of the air conditioning. The use of these masks is still not mandatory. This is incredible as the chief pilot himself recently admitted that the engine oil contains a neurotoxin and that we should expect urgent precautionary measures to be implemented. It is notable that there are no oxygen masks on board to protect the passengers from toxins.
On account of this the aircraft manufacturer also published an emergency procedure that must be used when smoke or fumes enter the aircraft. The procedure prescribes a landing as soon as possible - not in order to make life at Lufthansa CityLine difficult, but to protect the people on board. At Lufthansa CityLine the use of this procedure involving toxic fumes is not mandatory, but apparently the view is that the oil fumes are somehow not really “fumes”, but more a “smell” and therefore the pilots may continue flights on aircraft whose air conditioning systems have been contaminated with oil.
The fleet manager cheerfully wrote about “building site cabin air” in his letter. Maybe the building site manager is thinking of the adage ‘were wood is chopped, splinters must fall.’ In any case, I’m not sure whether our passengers would be happy with this image if they knew they were on a building site flying through the air.
At Aunt Törtchen’s house once the lies stopped there was a big party with music. Everyone made up with each other and danced late into the night - even the raven. Whether Aunt Törtchen would have invited the Lufthansa CityLine management, I don’t know.
Original German version ‘Auf der Baustelle der Wahrheit’, written 6 April 2010
Documentaries featuring the author
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Plusminus - Obligation to report disregarded Plusminus reported on Aerotoxic Syndrome in February. New documents show that incidences of contaminated cabin air in Germany are much more frequent than the airlines admit. (5 minutes) Interview with Prof Henschler German Version |
 | Airlines: Poison in aircraft? Although it has been known for decades that air contaminated with toxic substances can enter aircraft cabins, the airlines apparently still aren’t taking the dangers seriously enough. (31 March 2010, 8 minutes) Interview with author of the report (5 minutes, subtitles) Incidents that have been researched and verified |
