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Merged: Oxygen tanks topped up with Nitrogen

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Merged: Oxygen tanks topped up with Nitrogen

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Old 15th Dec 2007, 21:34
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Merged: Oxygen tanks topped up with Nitrogen

Perhaps another good reason why LAME's should not be reduced in numbers on the tarmac....................


Probe after Qantas pumps wrong gas into jets
Matthew Benns
December 16, 2007

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POTENTIALLY fatal gas being pumped into passenger jet emergency oxygen tanks in Australia has sparked a worldwide safety investigation.

The Australian Safety Transport Bureau confirmed yesterday that Qantas engineers accidentally put nitrogen into the emergency oxygen tanks of a Boeing 747 passenger jet at Melbourne Airport.

The Australian carrier immediately checked the oxygen supplies of more than 50 of its planes that had been serviced by the mislabelled nitrogen cart at the airport. But an aviation source said: "This could have affected hundreds of planes worldwide. Any international jet that passed through Melbourne and was serviced by Qantas could have had nitrogen pumped into its oxygen tanks."

Health experts warned that in an emergency the effects of nitrogen in the oxygen tanks could have potentially fatal results.

Dr Ian Millar, hyperbaric medicine unit director at The Alfred hospital, said: "If there was an emergency and the pilot took nitrogen instead of oxygen, instead of gaining control of the aircraft he would black out and it would be all over. It's a pretty serious mistake."

Nitrogen, which is non-flammable, is commonly used at airports to fill aircraft tyres. The aviation source said: "Qantas took delivery of the new nitrogen cart 10 months ago. It looked exactly like the old oxygen cart. When the attachments did not fit they went and took them off the old oxygen cart and started using it."

The mistake was eventually spotted by an aircraft engineer. "He was walking around the plane and asked what they were doing. When they said they were topping up the oxygen, he said, 'No you're not, that's a nitrogen cart'," said the source.

The incident was reported to the Civil Aviation Safety Bureau, which confirmed that an investigation detected nitrogen in the crew oxygen tanks on the Boeing 747-300. A bureau spokeswoman said it was a one-off incident.

But the aviation source said: "This has affected at least 175 planes and Qantas has had to tell any other airline that has been serviced in Melbourne to check out its oxygen supplies."

Air New Zealand was told about the problem six weeks ago. "As a result of receiving that letter we did take some precautionary measures," a spokeswoman said. "The oxygen tanks on a small number of planes were removed, checked, reserviced and refilled. No irregularities were found."

A spokeswoman for the Australian Transport Safety Bureau said: "Very clearly they (Qantas) needed to carry out a risk assessment because there was a chance that other aircraft were affected.

"They identified 21 that were at risk because they had had a reasonable amount of oxygen top-up, so there was a reasonable chance they had been contaminated. There were another 30 aircraft at minor risk because they have had minor top ups," said the spokeswoman. The planes were inspected and no positive results found.

She said the airline had turned the error into a learning exercise and informed engineers all over the world about the mistake. "They have talked to thousands of their engineers around Australia and overseas, informing them about this lesson that has been learnt," she said.

Qantas engineering executive general manager David Cox said: "We had a guy using a new rig and he inadvertently serviced the crew oxygen with nitrogen. He realised what he was doing and flagged it."

Mr Cox said that once the mistake had been realised, extensive safety checks were put in place to ensure no other aircraft had been contaminated and that it could never happen again.

"Every aircraft, including customer aircraft, that could have been touched with this rig has been checked," he said after confirming the rig had been in use at the airport for several months. Mr Cox said the airline had been completely open in informing all safety authorities, staff and other airlines about the mistake.


This story was found at: http://www.theage.com.au/articles/20...568332267.html
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Old 15th Dec 2007, 22:16
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Question PAX & Crew oxy tanks topped up with Nitrogen - Oops

I have heard that a QF 747 at Tulla had Oxy tanks topped up with Dry Nitro gas.... I can feel my eye balls bulging already... how can this happen... in my time at QE oxy carts were painted white and very clearly distinguishable from the Nitros which were red.....
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Old 15th Dec 2007, 22:29
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Heard this one, doesn't sound good, not sure how you could miss the bottle identification...

duhh

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Old 15th Dec 2007, 22:35
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There is an earlier post about the same issue, newspaper story included.

Please do not use this one, only a few minutes apart!!
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Old 15th Dec 2007, 22:40
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Assuming they used it in flight, would it be possible to get 'nitrogen narcosis' at altitude?

PS: This one is better titled to arouse interest!
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Old 15th Dec 2007, 22:45
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HH Yes true, who can delete the other or lock it!!

Just more info in the other one...
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Old 15th Dec 2007, 23:12
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Sorry about that - did not mean to hijack another post - however it is a really serious issue that deserves a specific subject heading ...
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Old 15th Dec 2007, 23:33
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Maybe, but are you sure about the qualifications of those who were servicing the oxygen system with the nitrogen cart?


Not that I'm a big fan of the abolition of FE's either! After all, most of them are ex LAME's
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Old 16th Dec 2007, 02:51
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Basic safety procedures should ensure that nitrogen fittings do not fit oxygen bottles.
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Old 16th Dec 2007, 02:56
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From original article:
"Qantas took delivery of the new nitrogen cart 10 months ago. It looked exactly like the old oxygen cart. When the attachments did not fit they went and took them off the old oxygen cart and started using it."
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Old 16th Dec 2007, 07:01
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So who were the 'industry professionals' who scoped out and oversighted the design of the new carts .......? did they consider 'human factors' issues ie. the new nitro carts should be clearly distinguishable from the new oxy carts... what about risk assessments and training on the new equipment... did a breakdown of 'due process' cause this..??
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Old 16th Dec 2007, 07:06
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Nice buzz words Shaman, but whatever happened to good old fashioned common sense? It seems to have been bogged down in a quagmire of arse covering!
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Old 16th Dec 2007, 07:27
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Thats a fair call Howard..... it is just such a bad stuff up with potenial catastrophic results ... I am really wondering how so many holes in the swiss cheese lined up,,,, lucky the last one did not ie. rapid depresurisation of the cabin at altitude..
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Old 16th Dec 2007, 10:29
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Dr Ian Millar, hyperbaric medicine unit director at The Alfred hospital, said: "If there was an emergency and the pilot took nitrogen instead of oxygen, instead of gaining control of the aircraft he would black out and it would be all over. It's a pretty serious mistake."
Is Dr Millar assuming the tanks were 100% full of Nitrogen?

When oxygen tanks are serviced, are they not simply topped up? Therefore would it not be fair to say that the tanks would be something like 95% Oxygen, and 5% Nitrogen?

Considering air is 78% Nitrogen, and 21% Oxygen, perhaps claiming that instant death would be inevitable is overstating it somewhat.

Of course I am not saying it is a serious matter, of course it is! I'm just pointing out that it may not be AS bad as first thought. (The partial pressure of oxygen is still 95% of what it would have been had it been serviced with oxygen bottles).

http://en.wikipedia.org/wiki/Earth's_atmosphere
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Old 16th Dec 2007, 10:40
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I'd like to know which "passenger" oxygen system can be topped up by a cart.

I'm all for saving engineering jobs but this leak has done little for the LAME jobs cause. Public perception of QF engineers over this nitrogen incident is not particularly sympathetic. In fact reaction has been to ask if you blokes know what you are doing. Hate to think if the same bloke had tried to service an oleo with oxygen!!!!!!!!

If you're going to make your point around Christmas time, at least pick a fight that makes you look good an will get Joe public on side.

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Old 16th Dec 2007, 11:08
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Buzzy.
passenger oxy on the 747 is from bottles, not chemical generators. its serviced via the same fill port as the crew oxy is.
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Old 16th Dec 2007, 11:26
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the old type of oxy and nitro carts used by QE were well marked and virtually impossible to confuse.... I am still puzzled as to how a 'new' nitro cart can be introduced into QE that can in anyway be confused / used for oxy servicing.....?? I think the persons responsible for commissioning and risk assessing this equipment may be a little red faced at the moment.
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Old 16th Dec 2007, 19:07
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common sense

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common sense is a wonderful concept, it's just not very common these days.
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Old 17th Dec 2007, 01:08
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Aren't the fittings of the oxy bottles different from the ones on the nitrogen so you cant mix them up.
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Old 17th Dec 2007, 02:25
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Is the gas label on the bottles visible when the bottles are on the cart? If so, would someone not notice "Oxygen" is not spelt N-i-t-r-o-g-e-n?
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