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Mandatory Occurrence Reports

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.



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.





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.



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.