CABIN AIR CONTAMINATION
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CABIN AIR CONTAMINATION
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Beyond the BAE-146, the MD-80 has a history of contaminant ingestion.
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AD/BAe 146/86 Environmental Control System
Inspection for Contamination 5/2001
TX
Applicability:
All British Aerospace BAe 146-100, -200 and -300 series aircraft.
Requirement:
1. At any time cabin air contamination is suspected to be associated with engine oil, carry out the inspections specified in British Aerospace Inspection Service Bulletin ISB.21-150, Paragraph 2A and 2B and the associated flow chart.
If defective components are found during these inspections, either rectify such defects before further flight or isolate the defective component/s and operate the aircraft in accordance with the limitations specified in the approved MEL.
2. Carry out the inspections specified in British Aerospace Inspection Service Bulletin ISB.21-150, Paragraph 2A and the associated flow chart.
The provision of Requirement 1 to invoke the MEL may be applied to this Requirement if required.
3. Report defects to British Aerospace in accordance with British Aerospace Inspection Service Bulletin ISB.21-150, Paragraph 2J.1 using the forms provided in the Service Bulletin. Additionally, whenever oil contamination of the cabin air system is confirmed, forward a copy of the associated report to CASA addressed to the Section Head, Systems, Fax No. 02 6217 1914.
Note 1: The CAA (UK) AD 002-03-2001 refers.
4. Ensure operating procedures include provisions for required action in the event of suspected cabin air contamination and for reporting such defects for maintenance action and that all flight crew are aware of those provisions.
Note 2: BAe 146/RJ Service Information Leaflet No21-45 and BAe 146/RJ Operational Notice OP 16 contain information with respect to required aircrew action in the event of a suspected cabin air contamination event. Such action includes specific provisions for oxygen usage by the flight crew.
Compliance:
1. Either before further flight or within 10 flying hours provided the source of the contamination is identified and isolated from the cabin environment before further flight, using either flight operations procedures or maintenance procedures.
2. Initially at the next A Check after the effective date of this Airworthiness Directive, and thereafter repeat the inspection at intervals not to exceed 500 flights.
3. As of the effective date of this Airworthiness Directive.
4. Unless previously accomplished, no later than 3 May 2001.
This Airworthiness Directive becomes effective on 3 April 2001.
Background:
Cabin air quality has been the subject of intense investigation for a number of years. As a result, local BAe 146 operators have incorporated various modifications to the cabin air system, APU and engines. They have also introduced improved maintenance practices to further address this issue. These actions have resulted in a significant reduction in the number of cabin contamination incidents reported to CASA and the ATSB. In addition, the operators have changed the oil used in their respective fleets to Mobil 291; a fourth generation turbine oil.
The CAA (UK) has advised a recent crew incapacitation incident in the UK may have been associated with contamination of the cabin air system with engine oil. While overseas operators have experienced cabin air contamination events, these events have not generally been treated with the same degree of concern, as is the case with Australian operators. Consequently, overseas operators have not been as active in introducing the cabin air quality improvements into their aircraft.
This AD reflects action by the CAA (UK) and effectively mandates action already enacted by local operators to address cabin air contamination events. It also serves to satisfy the recommendation by the Senate Rural and Regional Affairs and Transport References Committee for improved reporting of cabin air contamination events in Australia.
(Original Signed by)
Eugene Paul Holzapfel
Delegate of the Civil Aviation Safety Authority
30 March 2001
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Interview with Dick Best, former CASA Airworthiness Regional Manager. Tel 61 2 94765973
I was district airworthiness manager for CASA at Bankstown airport. I was part of the Australian team which introduced the Bae 146 300, and I signed the first certificate of airworthiness up at British Airways at Hatfiels for the East West airplanes. And as part of that process, I had a look at the histories of the aircraft in other operating environments.
Now the problem is that roughly 130 crew have gone ill…well they are medically affected by the aircraft. And what I said to Sue is that I think casa itself should have been in the know by receiving major defect reports from the operators of the aircraft in Australia to allow them to evaluate the situation and to talk to the British authorities who have the ultimate responsibility for the safety of the aircraft.
(Why wasn’t CASA informed of this problem?) Well, under the regulations, the Australian regulations, when the owner operator (CHECK !!) or pilot in command becomes aware of a major defect, or a person carrying out maintenance on the aircraft becomes aware of a major defect, they have to report it to CASA, and that process hasn’t been followed.
It’s right that Ansett and the other major carriers have been fully aware of the fumes problem since 1992. Casa was not informed of this by major defect reports…The crews haven’t been writing up the defects and therefore the pilots have not been conforming with the requirements of the regulations. And therefore there was no formal process which allowed Casa to be involved.
There is an element of fear in not reporting..Of being considered a trouble make or not in full health…But I think it goes back further than that…There has been a culture grown up with the pilots right frpm day one..when they start their flying training. They are in most cases prohibited from entering defects on the maintenance release because of a misconception that putting a defect of the maintenance release would ground the aircraft. And that has gone right through, and I think it’s just perpetrated all the way up through the pilot ranks all the way.
Civil Aviation Safety Regulation 248 requires them to report any defect at the conclusion of every flight or in an emergency during the currency of a flight. And then you get into the regulations, Reg. 50, which required defects to be endorsed on the maintenance release and the only way thjat a defect on the maintenace release can ground the aircraft is where the endorsement says that the aircraft is unairworthy. Unfortunately I don’t think a lot of people understand that.
Yes it’s true that there is a reluctance to become known as a trouble maker by writing up these reports. The problem is that in 1992 CASA withdrew Civil Aviation Order 100.8. And 100.8 was fairly specific. For example contamination of the air into the cabin or into the cockpit was considered to be a major defect. But when they withdrew that, it just left the generic terms in the regulation which required the person to think whether it was going to be a danger to person or property. And unfortunately, even by the Senate hearing, both the airlines and CASA believe that to be more of an occupational health and safety issue, rather than a safety issue.
Now I would put it to anyone (to distinguish between the two) ??
(Was it a coincidence or not that Reg 248 was withdrawn in 1992?? When there was a major problem with the aircraft??) Well I don’t think that CASA understood that there was a problem with the aircraft at that time. And the fact that the order was withdrawn took it out of the limelight that people had to report these things to CASA.
Casa, I don’t believe really knew about the problem. I didn’t know it at the time. The medical people at CASA should have been aware and should have been a little bit concerned when the number of people started toi be ill resulting from flying in the 146 aircraft.
(Do you think that the reason for the withdrawl of this regulation was the result of pressure from the industry?)
No…It was primarily that Ron Cooper who was the manager at the time started the process that went to a two level regulation system, and that was when they put a whole let of stuff into the regulations and they were expanding the regulations, and withdrawing the Civil Aviation orders. I think it was just coincidence, but the fact is that the clean air requirements go back in civil aviation order 101 where it calls up the standards which were enforced under the >British system, back to 1963, and I think the American system until about 1965. So those clean air requirements were there all the time. My colleague and I looked at the 146 300, we looked at problems which were being experienced overseas, and there was no indication that there was any problems with contaminated air, because the defects weren’t being reported overseas as well. All we were really worried about at the time was Carbon Dioxide and Monoxide into the cabin. We just didn’t know that there was going to be this sort of problem.
The British and American regulations still definitely apply to the 146…(Is this plane, the 146, airworthy according to the current international regulations?) I don’t believe it makes certification standards, in the fact that the wording is just clean air, and with these organic phosphates in the air it can’t be clean. Now the trouble is that with all the reports which should have been coming in..they should have gone to CASA, CASA should have talked to British Aerospace and the CAA UK who are the principal certifying authority for the Bae 146. And the emphasis should have been on British Aerospace and the CAA rectifying the problem and satisfying CASA that the aircraft was safe to fly in Australia.
(Does non certifiable mean that the 146 is not airworthy?) There is definitely a question of whether the aircraft is airworthy if it doesn’t meet the clean air standards. And of the clean air standards of the CAA in Britain. There is a real question mark as regards clean air for the 146.
Then there is the problem of the health of the crew…This becomes a safety problem. If the pilot becomes incapacitated and can’t do his duty, the aircraft is unsafe. This also applies to the cabin staff. I personally think that CASA should have applied themselves a bit better than they have…there were those two pilots who became incapacitated at the controls, and there is empirical evidence that has happened. And this both the plane and the passenger, and wherever it crashes in a bad position. Neither the medical sector of CASA or the executive has done anything….One reason is that the technical capacities of CASA have been downsized for economic cut back reasons. We used to have a world famous laboratory which has been down sized and the expertise has been spread around, like a lot of the expertise in Canberra.
Yes it’s true that instead of getting experts to consult and do research into the problem of the 146, CASA merely relied on the research carried out by Ansett itself. They relied on just what Ansett told them. It’s a dereliction of duty.(CHECK ON THIS WORDING) The regulator should be like a cricket umpire, and be impartial all the way.
And if there is any question of having 130 cabin crew ill, this should point to someone to say: hey we’ve got a problem here…let’s go and really ascertain in an impartial and independent way what the situation is.
If the pilots and the airlines don’t tell CASA, then CASA is not technically responsible. If the airline operators and the pilots etc are not meeting the requirements of the regulations themselves, then I don’t believe anyone in CASA, unless they became aware that there was a problem, would be technically responsible.
(It must have been very frustrating working in this environment??) That’s why I am not sorry that I have got a redundancy. The problem is that over the past ten years they have not provided enough specific training for regulator officers…no itty gritty stuff.
(Is there a case for grounding the 146?) It could be. I mean it’s been done for other aircraft before. The Viscount was put out of the air in Australia….They have changed the APU. It may be that operational procedures may be put in place which limit the amount of air which can be taken.
Don’t forget that with the contamination of the air you most probably are also getting degradation of the flammability standards within the cabin of the aircraft..and this should be really looked at as well. Because while the oil was ingesting itself into the cabin material, it is degrading the inflammabiility standards of that material in the case of an in cabin fire. No one seems to have picked up on this as yet.
With the 28,000 feet altitude limit imposed by CASA, I seem to remember the BAE and Allied signals managed to convince casa that with modifications it can return to its certified maximum altitude..But >I’m a bit rusty on this.
If I had a say now, I think there should be an in-depth impatial investigation to the situation to see if the plane is a danger when its got oil contamination coming through. To ground the aircraft straight out without having an impartial investigation……..There is empirical evidence that we do have a problem, a rewal problem with this aircraft.
The impartial commission could be chosen by the ministry…
There <are enough people, drawing from the people who have submitted to the senate to draw up a panel to find out what the real situation is.
To sum up: the plane’s airworthiness is definitely questionable. They may have to eventually lower the altitude and the number of passengers, or things like that…
The ageing of the plane is also a problem…An older plane definitely begins to leak air..window and door seals begin to wear and leak air..many other things.
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The December 2000 Aviation Air Quality Symposium Statement
Consensus statement made by attendees at the December 2000 Aviation Air Quality Symposium at the Australian Defence Force Academy campus of the UNSW in Canberra:
Symposium attendees:
1. Affirm and support the recommendations of the report of the Senate Inquiry into Oil Fumes on the BAe 146.
2. Urge the Commonwealth Government to implement all the recommendations in the report of the Senate Inquiry into Oil Fumes on the BAe 146 as fully and quickly as possible.
3. Deplore the absence of a representative of the Civil Aviation Safety Authority (CASA) from this symposium. The reasons given by CASA for not attending; that is, that the agency is too small to have technical specialists free and fumes are not viewed by CASA as an immediate threat to safety, are inadequate and unprofessional.
4. Consider that the mandatory reporting of odours and fumes as required under the current Civil Aviation legislation should be enforced more broadly than at present. This reporting should be both internally to the respective airline, and externally to CASA and the Australian Transport Safety Bureau (ATSB) as required under existing legislation and to third parties (for example, by listing on a website). This reporting should include recording of activities after the incident, such as any relevant activity that identified and resolved the problem.
5. Consider that the presence of contaminated air in the cabin of airplanes in flight is a major defect as well as an airworthiness issue, as specified in the current regulatory framework. Debate about this issue should not be centered on whether air is contaminated, but what to do when it is. In agreement with a recommendation from the Senate Inquiry report, such airplanes should be grounded after such incidents until the defect that caused the problem is identified and fixed. Information should be exchanged between the airlines, regulators and manufacturers in order to determine any trends that may be occurring.
Regulatory considerations:
1. As noted by the Senate Inquiry in their report, the Civil Aviation Safety Authority should provide reasons why regulations relating to air quality on passenger airplanes appeared to be disregarded (or in any event, not enforced).
2. It is apparent that some officers of the Civil Aviation Safety Authority are of the opinion that occupational health and safety of employees in the aviation industry is not part of their responsibilities. Because of confusion in (and outside) the aviation industry about who is responsible for occupational health of employees, the Civil Aviation Safety Authority should indicate those aspects of workplace safety that it considers are part of its responsibilities, with full references given to applicable Civil Aviation Regulations and legislation.
3. The terms “incident”, “major incident” and “safety deficiency” are defined in Section 19 of the Air Navigation Act.† The Civil Aviation Safety Authority should provide written reasons why they do not consider that the presence of contaminated air in the passenger cabins of commercial aircraft sufficient to cause irritation and discomfort (as has been reported from a range of sources) is not considered an aviation incident under this legislation.
4. The Civil Aviation Safety Authority should provide a transparent definition of the term “contaminated air”. If this definition includes such words as “hazardous” or “harmful” (or other similar terms), these terms should also be defined. This definition should be published.
5. In the past, circumstances have arisen where the air of the passenger cabin of airplanes on the ground and in flight has become contaminated sufficient to cause signs of irritation and discomfort in crew and passengers. There should be enforcement of the already mandatory reporting of circumstances such as odours and fume incidents in order to ensure that the regulations are adhered to. Such reporting should not be kept within the airplane operator, but should also be subject to external notification to the regulatory authorities CASA and the ATSB, and published (for example, on a website).
6. The Civil Aviation Safety Authority should develop criteria that allow for the recognition of circumstances when the cabin air is contaminated sufficient to be considered a major defect.
7. The term major defect is defined under Section 2 of the Civil Aviation Regulations as “a defect of such a kind that it may affect the safety of the aircraft or cause the aircraft to become a danger to person or property.” Superseded legislation described a major defect as: “defects causing or likely to cause smoke or gas contamination of any part of the cabin, cockpit or baggage compartment.” Current CASA published examples of major defects include “smoke, toxic or noxious fumes inside the aircraft.” The terms “toxic” and “noxious” should be defined.
8. The Civil Aviation Safety Authority should also develop improved criteria that allow the recognition of circumstances when cabin air is contaminated sufficient to be considered a major defect. Further, CASA should provide guidance for the defect categories for events where the presence of contaminated air gives rise to irritation and discomfort in crew and passengers,so that these can be appropriately reported. At present, these seem to be considered as “normal operations” or acceptable.
9. It is recognised that regulatory agencies, such as the Civil Aviation Safety Authority and the (former) Bureau of Air Safety Investigations (BASI) have resource limitations that, if overstretched, require priority setting in responding to matters for attention. However, such limitations should not prohibit such agencies from discharging their responsibilities.
Engineering considerations:
1. Any actions that will lead to a decrease (preferably a dramatic decrease) in engine oil and hydraulic leaks in engines in flight in planes being flown by Australian airlines should be strongly encouraged. Options for such actions include better engines (it is recognised that the cost of re-engineering planes can be prohibitive), better seals, the use of engine oils with less toxic ingredients.
2. There is a lack of information about the various options that have been considered and either adopted or rejected, and this leads to distrust. Of those that have been adopted, there is a lack of information about why they were chosen over others, and what criteria will be used to assess their effectiveness. CASA should provide a list of the options that it regards as being suitable for consideration in addressing the problem of engine oil leaks.†
3. The possibility of installing suitable monitoring technology, such as a sensor at the level of the bleed air inlet that could detect and warn about contamination of oil and hydraulics in bleed air needs serious consideration.
4. It must be recognised that once oil has entered the bleed air system, full cleaning downstream of the source (e.g. air ducts) as soon as practicable is required in addition to rectification of the leak.
Operational considerations:
1. An engine that is identified as leaking should be isolated and not used for bleed air purposes for the remainder of that flight. Full rectification of the causes of the leak in such a manner to prevent a leak from the same source from recurring must take place as soon as is practicable, and in any event, prior to further flight.
2. Airplanes with known problems of engine oil leaks into bleed air should only be flown with air circulation in the fresh air mode only (that is, no re-circulation) to the next suitable landing point.
3. Aircrew (either pilots or flight attendants) showing or reporting signs of intoxication after engine oil exposure should be required to sit down and be given oxygen through a respirator.
4. Aircrew (either pilots or flight attendants) showing or reporting signs of intoxication after engine oil exposure should be required to undergo medical evaluation immediately after landing, and as long as symptoms last after an exposure event. Such personnel should have blood samples taken for cholinesterase testing as part of this medical evaluation (guidelines on collection and storage of such samples should be developed by CASA). Samples should be made part of a chain of custody system, and analysed by a reputable laboratory, such as the NSW WorkCover Authority.
Worker health:
1. A procedure should be developed that allows concerned employees to come forward to discuss issues with management without penalty to career, seniority or benefits. Notwithstanding assertions made by the airlines to the contrary, such a procedure does not yet exist in any airline at present.
2. Airline operators should review the medical literature to identify a suitable test that allows identification of exposure to airborne contaminants during oil leak events. This test should be specific to the exposure (for example, the newer cholinesterase testing for organophosphate testing developed by the NSW WorkCover Authority). The results of this review should be made public.
3. The airlines should develop a database of symptoms that arise in aircrew, or are reported as being associated with airplane flight. Subject to suitable confidentiality requirements, this database should be accessible to third party bodies (for example, by inclusion on a website).
4. A study should be carried out investigating the role of long term tissue hypoxia in aircrew during flight, using pulse oximeters.
The attention of the aviation community should be drawn to the inequalities inherent in the unreasonable burden of proof required to establish health and safety matters (such as whether oil leak emissions can affect health), as compared with the trifling level of proof required that allows an existing practice (for example, a absurdly high level of engine oil leaks) to continue. The level of proof in both cases should be on the balance of probabilities, and not the level of proof required by scientific and statistical conventions.
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3 INCAPACITATION PROCEDURES
3.1 There have been a number of recent incidents where, due to smoke or fumes entering the aircraft, both
pilots of a Multi-Pilot aircraft have been affected to the extent that their ability to operate the aircraft may have been impaired. This highlighted two important training points; incapacitation drills and the use of oxygen masks.
3.2 Incapacitation Drills
Incapacitation drills have been designed to ensure the continued safe flight of a Multi-Pilot aircraft in the event that one of the pilots becomes incapacitated. The situation where both pilots become
incapacitated at the same time has been considered so remote that no procedures have been evolved to cope with the occurrence. However, it may be possible in the event of a malfunction in the engine or air conditioning systems which causes toxic fumes to enter the flight deck as has happened in a recent incident. Operators should, therefore, consider this possibility and provide some guidance to their crews, including cabin staff, to be aware of the chance of such an event.
3.2.1 The first action in the event of smoke or fumes in the flight deck should be for the flight crew to don oxygen masks and establish communications.
[This message has been edited by SKYDRIFTER (edited 04 April 2001).]
Beyond the BAE-146, the MD-80 has a history of contaminant ingestion.
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AD/BAe 146/86 Environmental Control System
Inspection for Contamination 5/2001
TX
Applicability:
All British Aerospace BAe 146-100, -200 and -300 series aircraft.
Requirement:
1. At any time cabin air contamination is suspected to be associated with engine oil, carry out the inspections specified in British Aerospace Inspection Service Bulletin ISB.21-150, Paragraph 2A and 2B and the associated flow chart.
If defective components are found during these inspections, either rectify such defects before further flight or isolate the defective component/s and operate the aircraft in accordance with the limitations specified in the approved MEL.
2. Carry out the inspections specified in British Aerospace Inspection Service Bulletin ISB.21-150, Paragraph 2A and the associated flow chart.
The provision of Requirement 1 to invoke the MEL may be applied to this Requirement if required.
3. Report defects to British Aerospace in accordance with British Aerospace Inspection Service Bulletin ISB.21-150, Paragraph 2J.1 using the forms provided in the Service Bulletin. Additionally, whenever oil contamination of the cabin air system is confirmed, forward a copy of the associated report to CASA addressed to the Section Head, Systems, Fax No. 02 6217 1914.
Note 1: The CAA (UK) AD 002-03-2001 refers.
4. Ensure operating procedures include provisions for required action in the event of suspected cabin air contamination and for reporting such defects for maintenance action and that all flight crew are aware of those provisions.
Note 2: BAe 146/RJ Service Information Leaflet No21-45 and BAe 146/RJ Operational Notice OP 16 contain information with respect to required aircrew action in the event of a suspected cabin air contamination event. Such action includes specific provisions for oxygen usage by the flight crew.
Compliance:
1. Either before further flight or within 10 flying hours provided the source of the contamination is identified and isolated from the cabin environment before further flight, using either flight operations procedures or maintenance procedures.
2. Initially at the next A Check after the effective date of this Airworthiness Directive, and thereafter repeat the inspection at intervals not to exceed 500 flights.
3. As of the effective date of this Airworthiness Directive.
4. Unless previously accomplished, no later than 3 May 2001.
This Airworthiness Directive becomes effective on 3 April 2001.
Background:
Cabin air quality has been the subject of intense investigation for a number of years. As a result, local BAe 146 operators have incorporated various modifications to the cabin air system, APU and engines. They have also introduced improved maintenance practices to further address this issue. These actions have resulted in a significant reduction in the number of cabin contamination incidents reported to CASA and the ATSB. In addition, the operators have changed the oil used in their respective fleets to Mobil 291; a fourth generation turbine oil.
The CAA (UK) has advised a recent crew incapacitation incident in the UK may have been associated with contamination of the cabin air system with engine oil. While overseas operators have experienced cabin air contamination events, these events have not generally been treated with the same degree of concern, as is the case with Australian operators. Consequently, overseas operators have not been as active in introducing the cabin air quality improvements into their aircraft.
This AD reflects action by the CAA (UK) and effectively mandates action already enacted by local operators to address cabin air contamination events. It also serves to satisfy the recommendation by the Senate Rural and Regional Affairs and Transport References Committee for improved reporting of cabin air contamination events in Australia.
(Original Signed by)
Eugene Paul Holzapfel
Delegate of the Civil Aviation Safety Authority
30 March 2001
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Interview with Dick Best, former CASA Airworthiness Regional Manager. Tel 61 2 94765973
I was district airworthiness manager for CASA at Bankstown airport. I was part of the Australian team which introduced the Bae 146 300, and I signed the first certificate of airworthiness up at British Airways at Hatfiels for the East West airplanes. And as part of that process, I had a look at the histories of the aircraft in other operating environments.
Now the problem is that roughly 130 crew have gone ill…well they are medically affected by the aircraft. And what I said to Sue is that I think casa itself should have been in the know by receiving major defect reports from the operators of the aircraft in Australia to allow them to evaluate the situation and to talk to the British authorities who have the ultimate responsibility for the safety of the aircraft.
(Why wasn’t CASA informed of this problem?) Well, under the regulations, the Australian regulations, when the owner operator (CHECK !!) or pilot in command becomes aware of a major defect, or a person carrying out maintenance on the aircraft becomes aware of a major defect, they have to report it to CASA, and that process hasn’t been followed.
It’s right that Ansett and the other major carriers have been fully aware of the fumes problem since 1992. Casa was not informed of this by major defect reports…The crews haven’t been writing up the defects and therefore the pilots have not been conforming with the requirements of the regulations. And therefore there was no formal process which allowed Casa to be involved.
There is an element of fear in not reporting..Of being considered a trouble make or not in full health…But I think it goes back further than that…There has been a culture grown up with the pilots right frpm day one..when they start their flying training. They are in most cases prohibited from entering defects on the maintenance release because of a misconception that putting a defect of the maintenance release would ground the aircraft. And that has gone right through, and I think it’s just perpetrated all the way up through the pilot ranks all the way.
Civil Aviation Safety Regulation 248 requires them to report any defect at the conclusion of every flight or in an emergency during the currency of a flight. And then you get into the regulations, Reg. 50, which required defects to be endorsed on the maintenance release and the only way thjat a defect on the maintenace release can ground the aircraft is where the endorsement says that the aircraft is unairworthy. Unfortunately I don’t think a lot of people understand that.
Yes it’s true that there is a reluctance to become known as a trouble maker by writing up these reports. The problem is that in 1992 CASA withdrew Civil Aviation Order 100.8. And 100.8 was fairly specific. For example contamination of the air into the cabin or into the cockpit was considered to be a major defect. But when they withdrew that, it just left the generic terms in the regulation which required the person to think whether it was going to be a danger to person or property. And unfortunately, even by the Senate hearing, both the airlines and CASA believe that to be more of an occupational health and safety issue, rather than a safety issue.
Now I would put it to anyone (to distinguish between the two) ??
(Was it a coincidence or not that Reg 248 was withdrawn in 1992?? When there was a major problem with the aircraft??) Well I don’t think that CASA understood that there was a problem with the aircraft at that time. And the fact that the order was withdrawn took it out of the limelight that people had to report these things to CASA.
Casa, I don’t believe really knew about the problem. I didn’t know it at the time. The medical people at CASA should have been aware and should have been a little bit concerned when the number of people started toi be ill resulting from flying in the 146 aircraft.
(Do you think that the reason for the withdrawl of this regulation was the result of pressure from the industry?)
No…It was primarily that Ron Cooper who was the manager at the time started the process that went to a two level regulation system, and that was when they put a whole let of stuff into the regulations and they were expanding the regulations, and withdrawing the Civil Aviation orders. I think it was just coincidence, but the fact is that the clean air requirements go back in civil aviation order 101 where it calls up the standards which were enforced under the >British system, back to 1963, and I think the American system until about 1965. So those clean air requirements were there all the time. My colleague and I looked at the 146 300, we looked at problems which were being experienced overseas, and there was no indication that there was any problems with contaminated air, because the defects weren’t being reported overseas as well. All we were really worried about at the time was Carbon Dioxide and Monoxide into the cabin. We just didn’t know that there was going to be this sort of problem.
The British and American regulations still definitely apply to the 146…(Is this plane, the 146, airworthy according to the current international regulations?) I don’t believe it makes certification standards, in the fact that the wording is just clean air, and with these organic phosphates in the air it can’t be clean. Now the trouble is that with all the reports which should have been coming in..they should have gone to CASA, CASA should have talked to British Aerospace and the CAA UK who are the principal certifying authority for the Bae 146. And the emphasis should have been on British Aerospace and the CAA rectifying the problem and satisfying CASA that the aircraft was safe to fly in Australia.
(Does non certifiable mean that the 146 is not airworthy?) There is definitely a question of whether the aircraft is airworthy if it doesn’t meet the clean air standards. And of the clean air standards of the CAA in Britain. There is a real question mark as regards clean air for the 146.
Then there is the problem of the health of the crew…This becomes a safety problem. If the pilot becomes incapacitated and can’t do his duty, the aircraft is unsafe. This also applies to the cabin staff. I personally think that CASA should have applied themselves a bit better than they have…there were those two pilots who became incapacitated at the controls, and there is empirical evidence that has happened. And this both the plane and the passenger, and wherever it crashes in a bad position. Neither the medical sector of CASA or the executive has done anything….One reason is that the technical capacities of CASA have been downsized for economic cut back reasons. We used to have a world famous laboratory which has been down sized and the expertise has been spread around, like a lot of the expertise in Canberra.
Yes it’s true that instead of getting experts to consult and do research into the problem of the 146, CASA merely relied on the research carried out by Ansett itself. They relied on just what Ansett told them. It’s a dereliction of duty.(CHECK ON THIS WORDING) The regulator should be like a cricket umpire, and be impartial all the way.
And if there is any question of having 130 cabin crew ill, this should point to someone to say: hey we’ve got a problem here…let’s go and really ascertain in an impartial and independent way what the situation is.
If the pilots and the airlines don’t tell CASA, then CASA is not technically responsible. If the airline operators and the pilots etc are not meeting the requirements of the regulations themselves, then I don’t believe anyone in CASA, unless they became aware that there was a problem, would be technically responsible.
(It must have been very frustrating working in this environment??) That’s why I am not sorry that I have got a redundancy. The problem is that over the past ten years they have not provided enough specific training for regulator officers…no itty gritty stuff.
(Is there a case for grounding the 146?) It could be. I mean it’s been done for other aircraft before. The Viscount was put out of the air in Australia….They have changed the APU. It may be that operational procedures may be put in place which limit the amount of air which can be taken.
Don’t forget that with the contamination of the air you most probably are also getting degradation of the flammability standards within the cabin of the aircraft..and this should be really looked at as well. Because while the oil was ingesting itself into the cabin material, it is degrading the inflammabiility standards of that material in the case of an in cabin fire. No one seems to have picked up on this as yet.
With the 28,000 feet altitude limit imposed by CASA, I seem to remember the BAE and Allied signals managed to convince casa that with modifications it can return to its certified maximum altitude..But >I’m a bit rusty on this.
If I had a say now, I think there should be an in-depth impatial investigation to the situation to see if the plane is a danger when its got oil contamination coming through. To ground the aircraft straight out without having an impartial investigation……..There is empirical evidence that we do have a problem, a rewal problem with this aircraft.
The impartial commission could be chosen by the ministry…
There <are enough people, drawing from the people who have submitted to the senate to draw up a panel to find out what the real situation is.
To sum up: the plane’s airworthiness is definitely questionable. They may have to eventually lower the altitude and the number of passengers, or things like that…
The ageing of the plane is also a problem…An older plane definitely begins to leak air..window and door seals begin to wear and leak air..many other things.
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The December 2000 Aviation Air Quality Symposium Statement
Consensus statement made by attendees at the December 2000 Aviation Air Quality Symposium at the Australian Defence Force Academy campus of the UNSW in Canberra:
Symposium attendees:
1. Affirm and support the recommendations of the report of the Senate Inquiry into Oil Fumes on the BAe 146.
2. Urge the Commonwealth Government to implement all the recommendations in the report of the Senate Inquiry into Oil Fumes on the BAe 146 as fully and quickly as possible.
3. Deplore the absence of a representative of the Civil Aviation Safety Authority (CASA) from this symposium. The reasons given by CASA for not attending; that is, that the agency is too small to have technical specialists free and fumes are not viewed by CASA as an immediate threat to safety, are inadequate and unprofessional.
4. Consider that the mandatory reporting of odours and fumes as required under the current Civil Aviation legislation should be enforced more broadly than at present. This reporting should be both internally to the respective airline, and externally to CASA and the Australian Transport Safety Bureau (ATSB) as required under existing legislation and to third parties (for example, by listing on a website). This reporting should include recording of activities after the incident, such as any relevant activity that identified and resolved the problem.
5. Consider that the presence of contaminated air in the cabin of airplanes in flight is a major defect as well as an airworthiness issue, as specified in the current regulatory framework. Debate about this issue should not be centered on whether air is contaminated, but what to do when it is. In agreement with a recommendation from the Senate Inquiry report, such airplanes should be grounded after such incidents until the defect that caused the problem is identified and fixed. Information should be exchanged between the airlines, regulators and manufacturers in order to determine any trends that may be occurring.
Regulatory considerations:
1. As noted by the Senate Inquiry in their report, the Civil Aviation Safety Authority should provide reasons why regulations relating to air quality on passenger airplanes appeared to be disregarded (or in any event, not enforced).
2. It is apparent that some officers of the Civil Aviation Safety Authority are of the opinion that occupational health and safety of employees in the aviation industry is not part of their responsibilities. Because of confusion in (and outside) the aviation industry about who is responsible for occupational health of employees, the Civil Aviation Safety Authority should indicate those aspects of workplace safety that it considers are part of its responsibilities, with full references given to applicable Civil Aviation Regulations and legislation.
3. The terms “incident”, “major incident” and “safety deficiency” are defined in Section 19 of the Air Navigation Act.† The Civil Aviation Safety Authority should provide written reasons why they do not consider that the presence of contaminated air in the passenger cabins of commercial aircraft sufficient to cause irritation and discomfort (as has been reported from a range of sources) is not considered an aviation incident under this legislation.
4. The Civil Aviation Safety Authority should provide a transparent definition of the term “contaminated air”. If this definition includes such words as “hazardous” or “harmful” (or other similar terms), these terms should also be defined. This definition should be published.
5. In the past, circumstances have arisen where the air of the passenger cabin of airplanes on the ground and in flight has become contaminated sufficient to cause signs of irritation and discomfort in crew and passengers. There should be enforcement of the already mandatory reporting of circumstances such as odours and fume incidents in order to ensure that the regulations are adhered to. Such reporting should not be kept within the airplane operator, but should also be subject to external notification to the regulatory authorities CASA and the ATSB, and published (for example, on a website).
6. The Civil Aviation Safety Authority should develop criteria that allow for the recognition of circumstances when the cabin air is contaminated sufficient to be considered a major defect.
7. The term major defect is defined under Section 2 of the Civil Aviation Regulations as “a defect of such a kind that it may affect the safety of the aircraft or cause the aircraft to become a danger to person or property.” Superseded legislation described a major defect as: “defects causing or likely to cause smoke or gas contamination of any part of the cabin, cockpit or baggage compartment.” Current CASA published examples of major defects include “smoke, toxic or noxious fumes inside the aircraft.” The terms “toxic” and “noxious” should be defined.
8. The Civil Aviation Safety Authority should also develop improved criteria that allow the recognition of circumstances when cabin air is contaminated sufficient to be considered a major defect. Further, CASA should provide guidance for the defect categories for events where the presence of contaminated air gives rise to irritation and discomfort in crew and passengers,so that these can be appropriately reported. At present, these seem to be considered as “normal operations” or acceptable.
9. It is recognised that regulatory agencies, such as the Civil Aviation Safety Authority and the (former) Bureau of Air Safety Investigations (BASI) have resource limitations that, if overstretched, require priority setting in responding to matters for attention. However, such limitations should not prohibit such agencies from discharging their responsibilities.
Engineering considerations:
1. Any actions that will lead to a decrease (preferably a dramatic decrease) in engine oil and hydraulic leaks in engines in flight in planes being flown by Australian airlines should be strongly encouraged. Options for such actions include better engines (it is recognised that the cost of re-engineering planes can be prohibitive), better seals, the use of engine oils with less toxic ingredients.
2. There is a lack of information about the various options that have been considered and either adopted or rejected, and this leads to distrust. Of those that have been adopted, there is a lack of information about why they were chosen over others, and what criteria will be used to assess their effectiveness. CASA should provide a list of the options that it regards as being suitable for consideration in addressing the problem of engine oil leaks.†
3. The possibility of installing suitable monitoring technology, such as a sensor at the level of the bleed air inlet that could detect and warn about contamination of oil and hydraulics in bleed air needs serious consideration.
4. It must be recognised that once oil has entered the bleed air system, full cleaning downstream of the source (e.g. air ducts) as soon as practicable is required in addition to rectification of the leak.
Operational considerations:
1. An engine that is identified as leaking should be isolated and not used for bleed air purposes for the remainder of that flight. Full rectification of the causes of the leak in such a manner to prevent a leak from the same source from recurring must take place as soon as is practicable, and in any event, prior to further flight.
2. Airplanes with known problems of engine oil leaks into bleed air should only be flown with air circulation in the fresh air mode only (that is, no re-circulation) to the next suitable landing point.
3. Aircrew (either pilots or flight attendants) showing or reporting signs of intoxication after engine oil exposure should be required to sit down and be given oxygen through a respirator.
4. Aircrew (either pilots or flight attendants) showing or reporting signs of intoxication after engine oil exposure should be required to undergo medical evaluation immediately after landing, and as long as symptoms last after an exposure event. Such personnel should have blood samples taken for cholinesterase testing as part of this medical evaluation (guidelines on collection and storage of such samples should be developed by CASA). Samples should be made part of a chain of custody system, and analysed by a reputable laboratory, such as the NSW WorkCover Authority.
Worker health:
1. A procedure should be developed that allows concerned employees to come forward to discuss issues with management without penalty to career, seniority or benefits. Notwithstanding assertions made by the airlines to the contrary, such a procedure does not yet exist in any airline at present.
2. Airline operators should review the medical literature to identify a suitable test that allows identification of exposure to airborne contaminants during oil leak events. This test should be specific to the exposure (for example, the newer cholinesterase testing for organophosphate testing developed by the NSW WorkCover Authority). The results of this review should be made public.
3. The airlines should develop a database of symptoms that arise in aircrew, or are reported as being associated with airplane flight. Subject to suitable confidentiality requirements, this database should be accessible to third party bodies (for example, by inclusion on a website).
4. A study should be carried out investigating the role of long term tissue hypoxia in aircrew during flight, using pulse oximeters.
The attention of the aviation community should be drawn to the inequalities inherent in the unreasonable burden of proof required to establish health and safety matters (such as whether oil leak emissions can affect health), as compared with the trifling level of proof required that allows an existing practice (for example, a absurdly high level of engine oil leaks) to continue. The level of proof in both cases should be on the balance of probabilities, and not the level of proof required by scientific and statistical conventions.
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3 INCAPACITATION PROCEDURES
3.1 There have been a number of recent incidents where, due to smoke or fumes entering the aircraft, both
pilots of a Multi-Pilot aircraft have been affected to the extent that their ability to operate the aircraft may have been impaired. This highlighted two important training points; incapacitation drills and the use of oxygen masks.
3.2 Incapacitation Drills
Incapacitation drills have been designed to ensure the continued safe flight of a Multi-Pilot aircraft in the event that one of the pilots becomes incapacitated. The situation where both pilots become
incapacitated at the same time has been considered so remote that no procedures have been evolved to cope with the occurrence. However, it may be possible in the event of a malfunction in the engine or air conditioning systems which causes toxic fumes to enter the flight deck as has happened in a recent incident. Operators should, therefore, consider this possibility and provide some guidance to their crews, including cabin staff, to be aware of the chance of such an event.
3.2.1 The first action in the event of smoke or fumes in the flight deck should be for the flight crew to don oxygen masks and establish communications.
[This message has been edited by SKYDRIFTER (edited 04 April 2001).]
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Safety isn't an issue if the recommended procedures are followed. Since we had a scare recently, we introduced a rigorous inspection regime, and have had no problems since.
Snooky is quite correct- the 757 has a long history of this, there was a diversion just a few months back with this problem. Contaminated cabin air can happen in ANY turbine-powered aircraft that uses bleed air from engines or APU for air conditioning.
If the Aussies issue an AD grounding the fleet- which I doubt they will- they will be consigning their operators to financial hell for a very long time- for no tangible benefit over current procedures. Better ground the 757s while they are at it, in fact why not ground all aircraft?
Better still, follow established engineering procedures, and the problem is not likely to recur!
Snooky is quite correct- the 757 has a long history of this, there was a diversion just a few months back with this problem. Contaminated cabin air can happen in ANY turbine-powered aircraft that uses bleed air from engines or APU for air conditioning.
If the Aussies issue an AD grounding the fleet- which I doubt they will- they will be consigning their operators to financial hell for a very long time- for no tangible benefit over current procedures. Better ground the 757s while they are at it, in fact why not ground all aircraft?
Better still, follow established engineering procedures, and the problem is not likely to recur!
Guest
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Effendi,
While AD's are of course safety related some of them have a 5 year implematation time - hardly flight critical.
Some are just confirming an already issued service bulletin and some just add a page to a flight manual.
Some are also issued as a legal CYA such as the AD that tells you to put nitrogen in the tyres!! (Standard practice!!)
They all have to be considered individually.
While AD's are of course safety related some of them have a 5 year implematation time - hardly flight critical.
Some are just confirming an already issued service bulletin and some just add a page to a flight manual.
Some are also issued as a legal CYA such as the AD that tells you to put nitrogen in the tyres!! (Standard practice!!)
They all have to be considered individually.
Guest
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This one has an implementation time of 3rd May, so I guess the authorities rate it as pretty urgent. Do you know what the UK incident was? I know the AAIB are producing a report on a KLM UK rollback, but the AD suggests a UK crew incapacitation, so I suppose they're also preparing another report on this.
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May be wrong as it's only a recollection, but 757 diverted CDG en route ZRH-LHR within the last couple of years. On the 757, it does'nt seem to have been taken as seriosly as the 146, maybe because it often only affects the flight deck.
I feel that this is a really serious issue, and in the future could end up with a similar situation to that caused by asbestos i.e. hundreds affected irreversably.
I feel that this is a really serious issue, and in the future could end up with a similar situation to that caused by asbestos i.e. hundreds affected irreversably.
