| Every month the Civil Aviation Authority (CAA) collates all the Mandatory Occurrence Reports (MORs) that they have received. These are reports on matters that affect flight safety and are submitted by aircrew of UK-registered airlines to their respective employers, who then forward them to the CAA.
At our request the CAA have been sending us the reports and we now look at a typical month, June 2010. We continue to be very concerned by the number of incidents concerning oil fumes.
June 2010
September 2010
October 2010
June 2010
There were 26 incidents of crew becoming ill and being removed from duty, in most cases no clue to the cause was given in the report. Of course oil fumes may not have been a factor in many of these cases, but in three incidents it was a clearly the major cause. Here are extracts from the three reports:
Aircraft type: Airbus A320
Pretitle: Cabin crew
illness/incapacitation due to suspected hypoxia/contaminated air. Oxygen
administered. Crew offloaded on return to UK.
Precis:
Crew felt unwell soon after take-off with symptoms of dizziness,
headache/light-headedness, difficulty breathing, strange taste in mouth,
hot/cold flushes, disorientation, blurred vision and inability to
concentrate on simple tasks during two sectors.
Aircraft Type: Bombardier Dash 8
Pretitle: Very
strong oily odour apparent in flight deck when engines set to low power
setting during descent, causing First Officer to feel unwell. Smell
persisted until engine shutdown.
Aircraft type: Airbus A321
Pretitle: Several members of the cabin crew became unwell during flight. Two crew members checked by paramedics on arrival.
Precis: The reporter states there had been repetitive bleed air faults with the aircraft.
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Main points of concern:
- A causal link shown between exposure to oil fumes and serious acute ill health symptoms (incapacitation) with clear flight safety implications
- Repetitive bleed air (air conditioning) system malfunction not rectified
- Various models of jet and turboprop aircraft affected.
- Limited information on follow up of ill health to aircrew
- No mention of assessment or follow up of passenger health - they are never asked.
While UK government research never ends, crew and passengers still continue to lose their health, cabin air quality solutions are available now. Why are we STILL waiting for something to be done?
September 2010
In June we looked at a typical month of Mandatory Occurrence Reports
(MORs), reports received by the Civil Aviation Authority (CAA) from
airlines on safety-related matters. We now examine September’s batch.
We’ve only included the ones that relate to oil fumes, although there
are more reports of crews becoming ill or incapacitated with no reason
given.
As with last time, we are struck by the apparent lack of concern for the
safety implications of contaminated cabin air, and also when a “fume
event” occurs and the source of the contamination cannot be identified,
the aircraft is simply put back into service.
For every report of
symptoms suffered by the aircrew, there could be potentially hundreds
of affected passengers. Who is following up on them? No one. They are
almost never informed that they have been exposed, so they go home and
after they get ill they don’t make the connection. We know of passengers
who’ve suffered years of illness before finally finding out why. How
many more will simply never know?
As the airlines continue to
play down the seriousness of the issue, even most aircrew are unaware of
the extent of the health effects caused by air contaminated by engine
oil. But on a positive note, one reporter talks about “Aerotoxic
Syndrome” in their report. So awareness is growing.
Aircraft type: A330-200 Engines: RR TRENT 700
Pretitle:
Strong unpleasant smell noted in the flight deck after power reduction
from the top of descent. The smell was also evident, but to a lesser
degree, in the cabin.
Precis: The First Officer reported a sore
throat after landing and the Captain felt a little light headed. Having
contacted their Maintrol, the crew were advised that there had recently
been an oil contamination issue with the air conditioning system.
Aircraft type: B777-200 Engines: RR TRENT 800
Pretitle: P2 post flight illness due to suspected carcinogenic fumes smelt on flight deck
Precis:
During cruise P2 noticed an unusual smell on flight deck. Flight
progressed as normal with no other reported event. However, three days
later P2 developed symptoms identical to 'Aerotoxic Syndrome' and medical tests have been carried out in liaison with company medical section.
Aircraft type: B757-200 Engines: RR RB211
Pretitle: Oil smell during climb followed by cabin altitude warning at FL360. Oxygen masks donned. Emergency descent to FL200.
Precis:
When oil smell evident RH air conditioning pack was switched off due to
previous history. Smell dissipated and climb continued. Approx 20mins
after top of climb cabin altitude reached 10000ft with associated
warning. During emergency descent RH pack was turned back on to aid
cabin altitude control and when a/c levelled at FL200 cabin altitude
reduced below 8000ft. Oxygen masks were removed and as oil smell was
again apparent, RH pack was once again turned off. Cabin altitude
reduced to 3000ft and a climb to FL240 was carried out to avoid
turbulence. CAA Closure: Investigations found that there was a duct
pressure loss reducing to 10psi. The Reverse Flow Check Controller
(RFCC) was replaced and an engine ground run carried out with duct
pressure normal. The event was reviewed at the operator's Safety Review
Board, which concluded that evaluation of flight data and monitoring
(FDM) of outflow valve position would be investigated as a predictive
tool for identifying precursors to these events. Routine work pack
carried out with no evidence of oil smell or odour being present during
the test. Fault isolation procedure 21.30.00 performed with no faults
found. The cabin pressure controller was replaced and three HPSOV sense
lines on the nr1 engine were replaced. A leak and operational check of
control pressure sense line, high pressure sense line and inlet pressure
sense line was carried out. Nr1 engine HPSOV and Hi-stage pilot valve
were replaced. Engine ground runs carried out with all systems normal.
Leak check of the pylon and wing leading edge and the air conditioning
bay, both left side, with no leaks found. During check flight it was
found that on a single pack operation the a/c was unable to maintain
duct pressure, cabin altitude rose and duct pressure was 10psi. The Fan
Air Modulating Valve (FAMV) was replaced and the a/c declared
serviceable.
Aircraft type: B777-200 Engines: GE 90
Pretitle: Oily smell noticed on flight deck for 2mins at FL210 whilst thrust increased from idle. The smell occurred again at FL180.
Precis: No fault could be found during post flight investigations
Aircraft type: A319-100 Engines: IAE V2500
Pretitle:
Strong smell of fumes in back galley, which dissipated and returned
briefly. After the event crew members experienced headaches and sore
throats.
Aircraft type: B757-200 Engines: RR RB211
Pretitle:
Transient fumes evident on flight deck during take-off roll and
descent. LH engine oil quantity found excessive. One quart of oil
drained from LH engine.
Precis: No oil leakage evident on LH and RH engines - a/c released to service.
Aircraft type: A319-100 Engines: CFM 56
Pretitle: Cabin crew illness due to suspected contaminated APU air.
Precis:
A fuel/gas smell was first noticed prior to departure and continued
throughout flight. After landing and following a 20min single engine
taxi with APU operating members of cabin crew reported tingling fingers,
headache and feeling sick with a metallic taste in throat. Flight deck
crew suspected contaminated APU air and in consultation with MOC APU
declared unserviceable. A/c ventilated and crew disembarked to get fresh
air until they felt fit to operate. On arrival back at base three
members of cabin crew felt unfit to continue duty and paramedics
requested. Emergency vehicles and HAZMAT team deployed.
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October 2010
More of the same ...
Aircraft Type: B757-200 Engines: RR RB 211
Pretitle: RH engine bleed failure.
Precis: EICAS 'AOA Probe Heat' warning following engine start. After the circuit breaker was pulled and reset, the fault did not recur. During the climb, flight crew and cabin crew noted a strong acrid smell. After reaching cruise height, EICAS indicated the RH engine bleed had shut down. In-flight return to the departure airport initiated. Both recirculation fans turned off, resulting in the cabin altitude increasing and the altitude warning illuminating. Two cabin crew members became ill. Three unsuccessful attempts made to reinstate the failed bleed system. Oxygen masks used by all crew on board. RH engine thrust reverser failed to operate and 'Forward Equipment Overheat' warning activated during landing.
CAA Closure: During investigations, equipment cooling fan filters were inspected and fan operation tested satisfactorily with no signs of overheat. High power engine ground runs were completed and the operation of engine bleed was found to be normal. Following a second occurrence, (EICAS indicated 'Engine Bleed Off'), the nr2 engine PRSOV (Pressure Reducing Shut Off Valve) was replaced, having been identified as the cause. It was also reported that the AOA probe warning and failure of the RH engine thrust reverser. These were unrelated defects, which initially were not reported by the pilot via Tech Log entries. Additional and separate actions were taken to close these defects and to remind flight crew of their obligations with regards to the reporting of defects. In addition, the forward equipment overheat warnings were the result of the recirculation fans being switched off during the event. Once reset, the warning was extinguished.
Aircraft Type: EMB-190 Series 200 Engines: GE CF34
Pretitle: MAYDAY declared due to burning smell within the a/c.
Precis: During final descent cabin crew informed flight deck of a burning smell within the cabin. At the same time the smell became apparent in the flight deck. ECL consulted which confirmed decision to declare MAYDAY. On short finals, EICAS 'Pack 2 Fail' and 'Pack 2 Off' annotated. Normal landing undertaken with fire service in attendance. Engineers subsequently confirmed ACS pack had become unserviceable.
Aircraft Type: A320-200 Engines: CFM 56
Pretitle: MAYDAY declared on ground due to smoke in cabin and cockpit
Precis: Whilst a/c on stand during boarding, cabin crew informed flight crew of the presence of smoke and a burning smell in the cabin, which also became present in the cockpit. Decision to disembark passengers during which intermittent ECAM 'Smoke fwd cargo' illuminated. MAYDAY declared for fire service attendance. After a/c disembarked, cargo hold checked for presence of smoke, none found and MAYDAY downgraded. During the disembarkation, the crew had difficulties contacting the fire service. During the investigations, multiple failures began to occur including TRIM air faults, engine fire loop fault, cargo vent fault and NAV IR 2 fault amongst others. The APU oil cooler was found leaking into air intake, which caused the smoke.
Aircraft Type: A320-200 Engines: IAE V2500
Pretitle: Fumes in flight deck and cabin. Precis: An acrid oil smell had been reported during the previous four sectors while in descent. Possible oil overfilling considered as a cause. On the outbound sector however, an acrid smell noted during descent when the engines were at idle thrust. On the subject flight, diversion initiated. At approximately FL200 during descent, the smell recurred, being markedly worse than before. Flight crew reported burning eyes, "thick heads" and an oil taste in the mouth. QRH for smoke/fumes actioned and the fumes immediately cleared. CAA Closure: Investigation by the operator revealed that the APU oil system was empty with oil migrating from the front bearing. APU failure is cited as the root cause and cause of the fume event. APU subsequently removed for repair and investigation. APU subsequently replaced.
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1. Aircraft type: Airbus A320
Pretitle: Cabin crew
illness/incapacitation due to suspected hypoxia/contaminated air. Oxygen
administered. Crew offloaded on return to UK.
Precis:
Crew felt unwell soon after take-off with symptoms of dizziness,
headache/light-headedness, difficulty breathing, strange taste in mouth,
hot/cold flushes, disorientation, blurred vision and inability to
concentrate on simple tasks during two sectors.
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