Toxic fumes incapacitate Germanwings crew

[txl]

A recent interim report from BFU, Germanys Federal Authority for Investigation of Air Accidents, indicates that toxic fumes nearly incapacitated both pilots of a Germanwings Airbus A319 on final to CGN. According to the report, during final turns the crew smelled something they described as "electrical", "sweet", "burning" and "dense", which made them feel dizzy. Although they put on their oxygen masks, they felt dizzy and a tingling sensation and almost passed out. Though heavily incapacitated, they managed to land the airplane and were treated medically. The incident, which the BFU labelled "severe", happened on Dec 19, 2010. Flight was Germanwings 5X018 from Vienna.

Report in German (http://www.bfu-web.de/cln_030/nn_1026502/DE/Publikationen/Zwischenberichte/ZB__2010/ZBericht__10__5X018__SmellInCockpit__K_C3_B6ln,templateId=ra w,property=publicationFile.pdf/ZBericht_10_5X018_SmellInCockpit_K%C3%B6ln.pdf) (PDF)

[Kerosene Kraut]

FO was unfit to fly for 6 months afterwards. German safety board BFU got told that crew would be okay and didn't initiate any further investigation first. Only a year later they received additional info and started some investigation.

[gwillie]

Airbus 'nearly crashed' when pilots fell ill - The Local (http://www.thelocal.de/national/20120928-45251.html)

[txl]

German media reports allege an attempted cover-up by Germanwings. The airline supposedly downplayed the incident when it informed BFU a day after the incident. BFU didn't see grounds for further invetigation then, daily newspaper "Die Welt" says. Only when new information was available a year later a thorough investigation was initiated. [Edit] Cockpit voice recordings had been deleted by then, flight data has been available for investigation.

A speaker for the Lufthansa-subsidiary denied these reports. Both Pilots had been fit to fly throughout the incident, neither ones ability to fly had been incapacitated, the newspaper quotes a Germanwings spokesperson.

According to the preliminary report by BFU, both pilots say otherwise. With the FO nearly unconscious, the Captain was "at the limit of his capacity" and suffering from "tunnel vision", the report says. The plane was coming in too fast on final. "As the Captain felt neither physically nor psychologically able to perform a go-around, he told the Co-Pilot that he would overrule the 1000 feet safety gate" in order to get the plane down a soon as possible.

[Dry wretched thunder]

I seen this in some of the older posts, it was the day after, looks very similar, Aircraft type too ???


http://www.pprune.org/rumours-news/472229-ba-flight-lhr-gla-returned-due-both-pilots-becoming-lightheaded-dizzy.html

[lomapaseo]

and the passenger :confused:

[Loose rivets]

What the heck did the smoke consist of??!!

[txl]

They don't know what the fumes consisted of. Passenger cabin wasn't affected.

Same aircraft (D-AGWK) is said to have had a similar incident a couple of years before (ca 2008) with passengers and cabin crew getting nauseous after inhaling "burny" fumes.

Aircraft has been checked after both events, with no diagnosis. No fire or burning had been detected. According to the report, airline technicians think that fumes might have been caused by de-icing-fluid getting into air intake of one engine.

[SLF68]

Quick question as SLF to all professional pilots out there.

Would auto-land not have been a better option in this case, given that the FO was more or less incapacitated and the captain "was at the upper limit of what he was capable to do in his bad bodily shape" (quote from avherald) ?

14L is CATIII and with the A-319 they could have done an auto-land with auto-roll-out down to taxi speed (according to the web).

Thanks for any input.

[Loose rivets]

One engine for the flightdeck air only?

[Annex14]

An independent aviation expert and pilot has stated - in German TV 1st channel - that he has studied the briefings of the two CM´s in depth. The captain has stated that the smell appeared to him not to be ingested and burned de-icing fluid but oil !!
Oil - if heated can release some very dangerous chemicals. That´s so his - the experts - statement - is what really happend.
The poisoning scheme of the two pilots fits in an oil contamination and not an de-icing fluid.
Similar - burned oil fumes in tap air - have happened before - with other flights of AB and LH, although the latter seem to denie any comment on that.

As far as I have read the air for the cockpit is normally tapped from the left engine, while the cabin is served from the right. That - if proves correct - will explain why there was nothing detected in the cabin.

[Dream Buster]

This will help anyone who has been exposed to oil fumes whilst flying:

Medical information (http://www.aerotoxic.org/about-aerotoxic-syndrome/advice-and-medical-help)

The official word is that there is 'no evidence' of ill health from oil fumes - but also there are officially 31 UK pilots grounded because of 'a suggestion of illness associated with the cabin environment'.

An earlier German TV report:

Interview - Gifte in Flugzeugen (1/3) Fume Event - ver.di FB/FFM September 2009 - YouTube

[Annex14]

Latest information spread in german media point towards a TCP - tricresylphosphate - contamination.
It is one of the questions raised here why TCP is withdrawn from use almost everywhere and at the same time is an additive used in jet engine lubricating oil in quantities of up to 5 vol. percent.
here an wikipedia report about that material.
Tricresyl phosphate - Wikipedia, the free encyclopedia (http://en.wikipedia.org/wiki/Tricresyl_phosphate)

[mickjoebill]

TCP - tricresylphosphate - contamination.

Is this and other toxic fumes checked for in pilots of fatal crashes?
Does it remain in the system and leave a trace?

[Annex14]

I don´t know since this was never part of my tasks during the time in Accident&Incident Investigation. However, seen the capabilities of modern Clinical Chemistry I assume it is checked routinely.
As for the case in question, a subtract of data from that BFU report.
The day after the incident the Co-Pilot went to the hospital again. The bloodcheck performed on that day revealed two substantial deviations from standard values:
Creatinase in general 26804 UI - normal value 0 - 170/200 UI
CK MB (heart reference) 270 UI - normal value 0 - 25 UI
Here also another Wikipedia copy:
Creatine kinase - Wikipedia, the free encyclopedia (http://en.wikipedia.org/wiki/Creatine_kinase)

What causes most of my concern is the fact that as long as that TCP is added to jet engine oil a similar incident can happen any time any where in the world again.

[cwatters]

With "burning" being mentioned wouldn't carbon monoxide be a concern? Doesn't that cause similar symptoms such as tunnel vision?

Carbon Monoxide - Pilots of America Message Board (http://www.pilotsofamerica.com/forum/showthread.php?t=160)

[OldBristolFreighter]

Surely if this left hand air supply theory is correct then it can only be a matter of time before a cabinful of S.L.F. become incapacitated, if the R.H. system is the same as the L.H.
However, if the L.H. system differs from the R.H. system, i.e. because one (main cabin) has to be of greater capacity, then the difference should provide a clue to the cause.

[Green Guard]

Why only on LH ?

and why only a cockpit became a Gas-Chamber ?

[hetfield]

Why only on LH ?

and why only a cockpit became a Gas-Chamber ?

Source LH Engine/Pack?

[B737NG]

Is more under the carpet then this issue within German Aviation. Time to look closer !

[Machinbird]

Surely if this left hand air supply theory is correct then it can only be a matter of time before a cabinful of S.L.F. become incapacitated, if the R.H. system is the same as the L.H.
One thing that has puzzled me in these incidents is the variability of human response to these fume incidents. One person strongly affected, another perhaps not so badly affected.

From this Wikipedia article on TCP Tricresyl phosphate - Wikipedia, the free encyclopedia (http://en.wikipedia.org/wiki/Tricresyl_phosphate), I picked up the following paragraph:
TCP's mechanism of action is similar to other organophosphates (http://en.wikipedia.org/wiki/Organophosphates) in that it can inhibit the enzyme acetylcholinesterase (http://en.wikipedia.org/wiki/Acetylcholinesterase), leading to a buildup of acetylcholine (http://en.wikipedia.org/wiki/Acetylcholine) in the synaptic space. This can lead to hyperactivity in cholinergic neurons in the brain and at neuromuscular junctions in the peripheral nervous system resulting in apoptosis (http://en.wikipedia.org/wiki/Apoptosis) of those cell-types. This is the reason for paralysis and other irreversible neurological problems.The word 'apoptosis' caught my eye. It means cell death.
In this case of a particular type of cell.

Just theorizing here:
Suppose you were picking up low levels of TCP exposure during you flying career? The damage to your neural system would be small but cumulative. Your body would have time to adapt.

Then add in a high level TCP exposure.
Your actual immediate physiological response to the event would be dependent on the level of exposure and your prior exposure history. (how many functioning cholinergic neurons you still have in reserve.)

Are there any non-toxic TCP alternatives available for engine oil?
Is there any way that one's level of TCP exposure damage could be measured?

[Dg800]

Is more under the carpet then this issue within German Aviation. Time to look closer !



:confused::confused: Can we get this in plain English please?

[noske]

Surely if this left hand air supply theory is correct then it can only be a matter of time before a cabinful of S.L.F. become incapacitated, if the R.H. system is the same as the L.H.

The BFU report is very specific that:


technicians who entered the cockpit 15 minutes after the plane had been parked still noticed an unusual smell, distinctive enough to identify it as "definitely not fuel, oil, or electricity, but most likely deicing fluid",
except for related announcements by the flight crew, the event was not even noticed in the cabin at all.

I don't know if the BFU will take these witness statements about deicing fluid at face value. But it seems to be a fact that the toxic fumes were confined to the cockpit, so understanding how that could be would help to narrow down their possible origin. Frustratingly, the report doesn't even attempt to do so.

I looked at the A319 air conditioning systems manual available at smartcockpit.com, but I don't think I really understand it. For example, it says that when the zone controller primary channel fails: "Pack 1 controls the cockpit temperature. Pack 2 controls the FWD and AFT cabin temperatures." But I can't reconcile that with the general flow chart at the beginning of the document, where it looks like the output of pack 1 and pack 2 is always combined first, before it is distributed to the three air conditioning zones. Oh well.

[Haleri]

Here the link to the new ITF campaign on cabin air quality.
International Transport Workers' Federation: Aircraft air quality (http://www.itfglobal.org/campaigns/cabin-air-quality.cfm)

[hetfield]

Concerning COC /CABIN, Pack1/Pack2.

There may be a different situation concerning smoke. Not only smoke out of the avionic compartment, but due to different installation of ducts etc.

I remember a cold winter day on 727 when soon after takeoff with wing AI ON the cabin was filled with white "smoke". Immediate call of the FA in the back. Smoke was so dense you couldn't see them from the cockpit.

Reason: wing anti ice turns on with air/grd sensor. Some gallons of water/coffe whatever fluid splashed out of the cabin floor on the wing anti ice ducts. A hose of the galley was disconnected and so the fluids accumulated.

In the Cockpit and fwd cabin the air was clear.

[Throb@30wCPDLC]

Chemistry I assume it is checked routinely


Never assume this......perhaps it needs to be checked??

A long campaign has been running by an ex employee of a large UK airline.....

More Q`s than answers I gather.

[txl]

A little update from the news front: The story has gathered some momentum recently, with the inevitable result of politicians getting involved.

According to media reports, there have been several similar incidents in the past 12 months, with flights being aborted or crews falling ill. Lufthansa has confirmed at least to similar incidents this year, among them an A330.

Meanwhile, German magazine "Der Spiegel" reports that oil is likely causing these incidents, not de-icing-fluid. The magazine quotes from documents by a Lufthansa aviation physician saying that "presumably flue gas and TCP inhalation" caused the Germanwings incident.

Lufthansa seems to be aware of the issue, as it's currently modifying engines, especially of its A380s. Also, the carrier is sponsoring development of a diagnostic tool to detect toxic fumes in cabin air.

German pilots union "Cockpit" demands immediate action by carriers. The "Bundestag" is set to deal with the issue in parliament this week. "Government has to acknowledge that there is a problem it can no longer ignore", a MP for the Green party is quoted.

[lomapaseo]

Also, the carrier is sponsoring development of a diagnostic tool to detect toxic fumes in cabin air.



Yea :ok:

Science to the rescue .... maybe

We seem to get perpetually wrapped around the axel (or conveyor belt) arguing about emotional beliefs that 99.9% of us don't understand their technical basis (greenhouse gases, volcanic ash, etc. cause-magnitude and effects )

[Whiskey Papa]

FO - Captain, the cabin air toxic fume detector is going off! What shall we do?

Captain - Either turn the engines off or hold your breath!

FO - Err.. How about winding the windows down?

Captain - You been talking to that Mitt Romney guy? (Cough, cough...)

[Germanflyer]

Oil was the factor. And cockpit's 'demands' have been respectfully accepted.
There is an interim order to fit 6 sensors(initially), through the length of its small bus fleet initially, followed by the blue whale.
Don't know if that will help matters but it is a start.

[Annex14]

Digging in several sites I have found a press report in "Die Welt" from 2010 and one in "Der Spiegel" from 2011. Here the links - unfortunately only in German - couldn´t find the English version.
"Es gibt weniger giftige Alternativen" - Nachrichten Welt Print - Wissen - DIE WELT (http://www.welt.de/welt_print/wissen/article6044262/Es-gibt-weniger-giftige-Alternativen.html)
and
DER SPIEGEL*9/2011 - Gestank alter Socken (http://www.spiegel.de/spiegel/print/d-77222653.html)
Especially the interview in "Die Welt" is interesting since the scientist interviewed already in the mid 50`s performed a study on the tocix potential of TCP. He found that there is in fact no tolerance value acceptable because of the damage even smallest amounts of that chemical does to nerve tracts.
To avoid further possible poisoning of crews and passengers there seems to be only two possibilities.
Nr. 1 Avoid usage of TCP in Jet Engine Oil at all, use a safe substitute
or
Nr. 2 Copy Boeings recent decision to delete bleed air from air supply in
airliners and use seperate compressors and filters, like they did in the new
B 787.

[Dg800]

FO - Captain, the cabin air toxic fume detector is going off! What shall we do?

How about donning oxygen masks before you both pass out and dig a smoking hole in the ground? :ok: Of course this is only a stop-gap measure, not spilling air from the engines any more is the only definitive solution.

[HAWK21M]

If this did not reoccur on subsequent flights....How would you suspect Oil fumes thru the bleed air.....It looks like fumes from a leak cargo....was there a DG cargo on board.

[noske]

The BFU report says that maintenance actions carried out after the incident include:


cockpit instrument ventilation fans were replaced, however no contamination was found
no. 1 engine: air intake area was examined, without any findings, engine core washed
flight crew oxygen masks replaced
engine ground run in accordance with maintenance manual, no smell on board observed

I admit that item #2 kind of answers my previous question: Apparently there is a scenario where contaminated air from the engines can affect the cockpit only (and if so, then egine no. 1 is at fault).

What I don't get is how Mr. Handwerg of the Cockpit association can be so sure that fumes from engine oil and not deicing fluid are to blame. He points out the low blood oxygen levels, but IMO that just proves that both crew were poisoned by something. And even regarding the creatine kinase values, Der Spiegel has to admit that the experts that they asked (physicians at the university hospital Hamburg-Eppendorf and this "society for clinical chemistry and laboratory medicine") cannot conclude anything specific from it.

Oil was the factor. And cockpit's 'demands' have been respectfully accepted.
There is an interim order to fit 6 sensors(initially), through the length of its small bus fleet initially, followed by the blue whale.
Don't know if that will help matters but it is a start.

Sensors capable of detecting TCP? I hadn't heard of that before, but if that's an actual option, it sounds like a good idea.

[Clandestino]

Trycresyl phosphate is neurotoxin. It wouldn't cause blood oxygen saturation to drop.

[lakerman]

I do not know where the suprise on all this comes from. The dirty sock smell has been apparent on aircraft for over 30 years or more. The most common affected aircraft were the B757 and the BAe146 series of aircraft It was common on the ALF502 engine where one of the seals used to fail, a lot of history on this in the Australian press going back to the 1980's.
Manufacturers always deny there is a problem, blame maintenance practises, but fault lies in the design of the engine air system. Hopefully, with the 787 which is bleedless, this will go away, but not on older aircraft.

[cwatters]

Trycresyl phosphate is neurotoxin. It wouldn't cause blood oxygen saturation to drop.

Carbon monoxide could do that (and tunnel vision) but I couldn't google up any reports of it being a known issue on jets (lots on GA/prop). However it seems some are concerned about CO...

http://www.holidaytravelwatch.net/wp-content/uploads/2008/03/carbon-monoxide-in-the-air.pdf

The AAIB did not dismiss the notion that the crew and passengers of the Birmingham flight were not exposed to CO (they could not find CO at any appreciable level), but did concede that exposure to neurotoxins or CO could produce the same symptoms.

In 2002, a Professor Nazaroff testified before the US House of Representatives, concluding that “During abnormal operating conditions, exposure to engine oils, hydraulic fluids, and their degradation products (such as CO and Formaldehyde) might occur. No data have definitely linked exposure to these compounds with reported effects in cabin occupants”.

He also called for CO monitors to be placed in cabins and for an enquiry into the ‘toxicity’ of the constituents of the oils or their ‘degradation products’.

The few papers I found on cabin air quality all seem to report CO within FAA limits.

Do you have CO monitors? Credit card size CO detectors are available on places like ebay.

[stator vane]

they might already have been checking for toxins in the crash pilots, but if we put ourselves in their (not the pilots!) place, would we want to let that out and remove our favourite default cause of any aviation accident?

why then we would have to admit that the aircraft manufacturer or owner might have some culpability in said accidents! (translate into loss of money)

[Morane]

@cwatters

the report says oxygen bloob saturisation quickly recovers under medical treatment of the pilots. So definetly no CO.

[zerograv]

I don't think that the "De-icing fluid" theory makes any sense. If the event had happen at the begining of the flight, may be, but at the end of something like 1 hour flight, I don't think so.

There seems to be quite a remarkable coincidence in terms of Engines involded in this fume events.

-the B757, which seems to have a "tradition" on the subject, has RR engines. (It is also powered with PW engines but I'm not aware of this engines causing any fume events)
-this Germanwings A319 has IAE engines which, one of the manufactors contributing to this engine is .... RR. (I believe that the IAE also has MTU on it, and this is probably the reason why Germanwings switched from CFM to IAE)
-the A330s of Lufthansa have .... you guess it right .... RR engines.

Wondering if RR is overdoing the lubrication of its engines?

[Prince Niccolo M]

some light reading:

http://www.aph.gov.au/Parliamentary_Business/Committees/Senate_Committees?url=rrat_ctte/completed_inquiries/1999-02/bae/report/report.pdf

[beamender99]

The UK Sunday Telegraph has an item with an A380 pictured.

"Lufthansa wakes up to the danger of intoxicating fumes in the cockpit"
(I cannot find the article online)

[smileandwaveboys]

Zerograv, it's the oil, not the engines that is the main problem. Accusations of RR being the cause, even on consortium engines, are not helpful or reasonable.

It is an established fact that most aero oils contain TCP as an anti-wear additive and that it breaks down under temperatures of over 100degC or so into organophosphates, the effects of which have been well observed in the farming industry. Bleed air temperatures are well in excess of this temperature required for this to occur. This is commonly associated with a smell of dirty socks and is experienced on most aircraft from time to time - I have had that smell numerous times on 737s, typically descending at idle thrust below FL100.

Hydraulic fluid also causes similar problems if it migrates from the reservoirs up into the pneumatic manifold, and is associated with a smell of pear drop sweets.

Do a web search for "aerotoxic syndrome" It's nothing new and has been hidden and denied by the industry and authorities for decades. I see the denial as attempted murder, personally, and would like to see those in position to deal with it but who ignore it swing.

[Dream Buster]

LUFTHANSA WAKES UP TO THE DANGER OF INTOXICATING FUMES IN THE COCKPIT.


The German press has lately been excitedly reporting on an admission by Lufthansa that, in 2010, an Airbus flight landing at Cologne only narrowly avoided a major disaster when its two pilots were severely incapacitated by toxic fumes from air recirculated into the airliner from its engines.

Back in June 2007, I was reporting here (http://www.telegraph.co.uk/news/uknews/1555466/Christopher-Bookers-notebook.html) how dozens of similar incidents affecting aircrew had been covered up because many airliners draw cabin air from their engines, contaminated by organophosphate (OP) chemicals used to reduce wear.

Several senior pilots who were forced to retire early are suffering in this way had teamed up with expert scientists and doctors to expose this system's potentially disastrous effects. But they met with a blanket denials from the officialdom and aviation industries of Britain, the US and Australia, because these tricresyl phosphates had been officially approved as safe. Any admission of the problem could have set off an avalanche of compensation claims.

In the 1990's, I ran a long campaign here to expose a similar cover-up of the tragedy befalling thousands of sheep farmers whose health and lives were destroyed after they were forced to dip their animals in OP compounds similarly licensed as safe to use.

I was eventually able to reveal a secret report confirming this by the Health and Safety Executive, but suppressed for the same reason when John Gummer was agriculture minister.

Lufthansa may now have caused a stir in Germany by announcing that its A 380 airliner fleet is to be "upgraded" to end the risk from these "oil fumes". But it has not yet come clean about the mass of scientific evidence (reported in my book Scared to Death) which links the problem directly to the tricresyl phosphates still being pumped into airliners carrying millions of passengers a year.

For more see Aerotoxic Association - Support for sufferers of Aerotoxic Syndrome (http://www.aerotoxic.org)

[hetfield]

Today a LH A321 FRA-IST diverted to MUC due to fumes in the cabin.

Lufthansa: Verdächtiger Geruch zwingt Airbus zur Sicherheitslandung - SPIEGEL ONLINE (http://www.spiegel.de/panorama/lufthansa-verdaechtiger-geruch-zwingt-airbus-zur-sicherheitslandung-a-861168.html)

[lederhosen]

The report says fumes seemed to be coming from cargo in this case. However I suspect an increasing number of us know colleagues who have been involved in incidents like the Germanwings one. They are deeply worrying at two levels. Pilot incapacitation possibilities over the middle of the ocean for example do not bear thinking about. The long term health issues for those exposed are also not looking good. The colleague I know who was involved in a documented incident suggested certain individuals seem to be more susceptible to showing immediate symptoms, but that does not mean the rest of us will have no long term effects.

[villarroel]

Any information of Dangerous Goods onboard?

[SPA83]

EASA DECISION No 2012/001/R
OF THE EXECUTIVE DIRECTOR OF THE EUROPEAN AVIATION SAFETY AGENCY


OF

27TH JANUARY 2012
on termination of rulemaking task 25.035 ‘Cabin air quality on board Large Aeroplanes’ without amending EASA regulations

The Agency has been made aware that some stakeholders (some pilots, cabin crews and some of their staff unions, some passengers and some consumers associations) have expressed concerns regarding the risk of contamination of cabin air on board commercial large aeroplanes, in particular the risk of contamination by lubricating oil and hydraulic fluid used in engines and auxiliary power units, on aircraft using bleed air architectures to feed air conditioning systems.

HAS DECIDED:
Article 1
The Agency concludes that, based on currently available reports and evidences, there is no safety case that would justify an immediate and general rulemaking action.

[Dream Buster]

EASA will be forced to 'remake' the rules - when The Courts finally make them:

Terry Williams settlement against Boeing (http://www.aerotoxic.org/news-and-articles/643-terry-williams-settlement-against-boeing)

East West Airlines v Turner - appeal dismissed ... twice (http://www.aerotoxic.org/news-and-articles/482-east-west-airlines-v-turner-appeal-dismissed)

And here is more proof, as Thomson Airways get in ahead of their competition:

Thomson Airways' Dreamliner Advert - "Designed for You" (http://www.aerotoxic.org/news-and-articles/742-thompson-airlines-dreamliner-advert)

[lomapaseo]

[quote]EASA will be forced to 'remake' the rules - when The Courts finally make them:

[/quote}

Courts don't make rules nor enforce them when another governmental body has been tasked to do so.

I'm afraid all you can expect is damages if you can prove harm under existing tort laws.

For the time being you should minimize any hazards that you feel are present by avoiding the circumstances or protection of some sort.

I do the same in hay fever season since my sinuses are more sensitive than others.

[torquewrench]

For the time being you should minimize any hazards that you feel are present by avoiding the circumstances or protection of some sort."Avoiding the circumstances" requires staying away from aircraft which provide bleed derived air to the cabin and flight deck. Not a viable option for flight crew, unless they fly the 787, or the classic DC-8, or a few other rare types which do not rely upon bleed air for pressurization.

As for "protection of some sort", you must either use bottled oxygen, or wear a respirator with an organic-vapor filter. For the entire time that you are in a bleed air environment. Easy!

[Croqueteer]

:sad:I lost my kidneys after 17 years on the 146, triggered by my immune system, probably due to organophospates. The consultant asked me if I had been exposed to oil. Farmers had similar problems with sheep dip.