Near disaster after warning stink ignored
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Crew of Norewgian air ambulance mistook warning smell of fire for farting patient
From today's Aftenposten [Norway]
Original article
Moral: Beware cabbage smells in cabin!
Near disaster after warning stink ignored
The crew of an air ambulance got an early warning sign that their craft had technical problems but chose to ignore it. The odd smell that they attributed to a gassy patient turned out to be the first signs of a dramatic fire in the front window.
The Aircraft Accident Investigation Board released a new report on the blaze that nearly ended in catastrophe on an air ambulance run from Hammerfest to Kirkenes in November 2001. The report reveals that the crew misunderstood a crucial warning sign.
"Approximately over Alta the crew noticed an indeterminable smell in the plane. It smelled most like cabbage. After two to three minutes it went away by itself. The crew assumed that the smell could be coming from the patient lying in the cabin," the report said.
Ambulance chief Geir-Arne Soerensen of Air Transport, the company responsible for the flight, believes that it was a logical conclusion.
"Everyone who has flown knows that gases arise that need to slip out. It isn't unusual that this happens to our patients," Soerensen said.
But when on a later flight that day, the crew noticed an even stronger version of the smell with a new patient aboard.
"So much gas can't arise from two different patients in one day," Soerensen said.
The real reason for the growing stench became clear when smoke appeared in the cabin. Within seconds a fire broke out, with 15-20 centimeter long flames flickering up from the front window. Despite frantic efforts with a fire extinguisher, the flames flared up three more times.
Five minutes later a loud report sounded as the pilot's window cracked, making vision impossible. The co-pilot managed to bring the plane down, where an emergency evacuation was carried out since the now familiar smell reappeared.
An investigation traced the stench to melting wire isolation and this type of window is being removed from all Norwegian planes.
The commission ruled that the crew performed admirably during the emergency.
The crew of an air ambulance got an early warning sign that their craft had technical problems but chose to ignore it. The odd smell that they attributed to a gassy patient turned out to be the first signs of a dramatic fire in the front window.
The Aircraft Accident Investigation Board released a new report on the blaze that nearly ended in catastrophe on an air ambulance run from Hammerfest to Kirkenes in November 2001. The report reveals that the crew misunderstood a crucial warning sign.
"Approximately over Alta the crew noticed an indeterminable smell in the plane. It smelled most like cabbage. After two to three minutes it went away by itself. The crew assumed that the smell could be coming from the patient lying in the cabin," the report said.
Ambulance chief Geir-Arne Soerensen of Air Transport, the company responsible for the flight, believes that it was a logical conclusion.
"Everyone who has flown knows that gases arise that need to slip out. It isn't unusual that this happens to our patients," Soerensen said.
But when on a later flight that day, the crew noticed an even stronger version of the smell with a new patient aboard.
"So much gas can't arise from two different patients in one day," Soerensen said.
The real reason for the growing stench became clear when smoke appeared in the cabin. Within seconds a fire broke out, with 15-20 centimeter long flames flickering up from the front window. Despite frantic efforts with a fire extinguisher, the flames flared up three more times.
Five minutes later a loud report sounded as the pilot's window cracked, making vision impossible. The co-pilot managed to bring the plane down, where an emergency evacuation was carried out since the now familiar smell reappeared.
An investigation traced the stench to melting wire isolation and this type of window is being removed from all Norwegian planes.
The commission ruled that the crew performed admirably during the emergency.
Moral: Beware cabbage smells in cabin!
Cannot find a link to the original report (not aftenpostens!) on the web anywhere in either english or norwegian.
And is it a fixed wing "plane" or a Eurocopter "plane". I didn't think the norsk luftambulanse had any fixed wing a/c?
Can anyone pls clear that up?
And is it a fixed wing "plane" or a Eurocopter "plane". I didn't think the norsk luftambulanse had any fixed wing a/c?
Can anyone pls clear that up?
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Did they really continue flight for 5 minutes after the flames shot up several times? And in a helicopter? Or did something get lost in the translation somewhere (like Norwegian to English, facts to newspaper article
)?
I would think that a visible fire would be a "land ASAP" situation in any helicopter, anywhere.
)?I would think that a visible fire would be a "land ASAP" situation in any helicopter, anywhere.
A Translation
My translation of part of the above site... It's 14 years since I spend 12 months in Norway, and since then my norwegian has gone a bit rusty so forgive me. These days it's used to try and charm young blonde scandy backpackers in Australia, not translate technical documents. 
-type og reg.: Beech Super King Air B200/ LN-MOE
-year manufactured 1993
-engines: 2 X. PT6A-42
Radio channel signal?: LTR 61
Date time: 8. november 2001, kl. 1634
Position : Near Seida VOR FL210
Type of emergence: Emergency in flight - fire in cockpit
Type of flight Aerial ambulance
Weather: Clear with the ground in sight
Light status: Dark
Flight conditions: VMC
Flight plan: IFR
Total on board 3 crew + 1 patient
injuries: None
Aircraft damage Completely shattered left front window
Other damage None
Captain
-sex/age Male, 48 years
-Licence: ATPL-A
-experience: Flight time total: 4 813:30 hours, multi engine: 4 363:30 hours. Instrument total: 2 496:30 hours. Night : 1 669:50 horus. Time on type 2 150:00 timer. Time on type last 90 days: 72:05 hours, instrument time 56:20 hours, night: 22:15 hours. Total flight time last 30 days/ 3 days/ 24 hours: 32:55 hours/ 6:15 hours/ 3:50 hours. This flight 0:50 hours. Landings last 90 days: 48. Total hours since last sleep: 8:30 hours.
Factual information
The crew started the day with a flight from Kirkenes to Tromso. About over Alta at Fl260 the crew noted an unusual smell in the aircraft (it smelt most like cabbage). No smoke was observed
The medical crew searched the cabin, but could not find anything unusual. After 2-3 minutes, the smell disappeared by itself. The crew too that the smell could have come from the pateint who farted in the cabin.
The following flight from Tromso to Hammerfest went normally. At 1614, the aircraft took off from Hammerfest and set course for Kirkenes and established itself at the cruise height of FL210.
15nm west of the Seida VOR the crew again noticed the same smell they had observed earlier in the day, but now it was more intense.
Simultaneously they observed smoke in the cockpit. The procedure for smoke evacuation was begun immediately.
The crew donned oxygenmasks and at the same time the passenger oxygen was activated.
Beskyttelsesbriller mot røyk ble vurdert tatt i bruk, men fordi røyken ikke var særlig tykk eller irriterende, ble dette tiltaket ikke ansett som nødvendig.
The ?? against smoke was activated, but because the smoke was not too thick nor irritating, this was not so urgent.??
Seconds after the crew had donned the oxygen masks, 15-20cm long flames began to flicker from the lower right corner of the left front window. The first officer requested to take the fire extinguisher from under his seat and simultaneuosly the captain disengaged the autopilot and began an emergency descent.
The first officer meanwhile had difficulties with getting loose the fireextinguisher because he was not clear that it was secured with two clamps and because he had to feel his way (under his seat). He loosened the one clamp and ripped the other one right off and gave the captain the fire extinguisher. The captain handed over control of the aircraft to the first officer and began to extinguish (the fire). After the fire had flared up again three times he succeeded.
Whilst the first officer struggled to release the fire extinguisher, the Captain called Bodo kontrol and gave a mayday call with a short description of what had occurred. Because the captain was worried that the fire would flare up again, he asked the nurse to come forward with the fire extinguisher from the cabin.
The extinguisher was brought forward to the cockpit and pulled out the pin ready to use.
All electrical systems were turned off and turned on again in order to try and isolate the problem. It was clear that the fire had to stem from the heating elements in the windscreen. The switches for "Windshield Anti-Ice were then switched off. This was unproblematic as there were no icing condtions.
(It is standard procedure that Windshield Anti-Ice shall be enabled?? on the Before Taxi Checklist and remain on for the whole flight because the windows are more likely to withstand against impact e.g. birdstrike)
The Captain considered whether he should fly to Vadso instead of Kirkenes as it was 10 nm closer. But because the situation was under control, together with the fact that Kirkenes had longer runways and better rescue services, he chose to continue to Kirkenes.
In addition, they had visual contact with both airports ?? (slik at avgjørelsen lett kunne endres??).
They began to go through the points on the emergency checklist but were not finished when the heard a loud bang and saw that the window in front of the Captain had broken. 5 minutes has passed since the fire had started. Because it was nearly impossible to see through the window, the captain handed over control of the aircraft to the first officer, and at the same time reduced the speed to 170kts. The emergency checklist was completed.
They were lined up for a visual approach to runway 24. The nurse was informed of the situation. She on her side could communicate with the captain that the situation in the cabin was under control. Then Bodo control instructed the crew to contact the Kirkenes control tower.
Vakthavende flygeleder ble orientert om at situasjonen syntes å være under kontroll og at fartøysjefen ønsket på flyplassen.
The tower controllers were told that the situation seemed to be under control and that the captain wanted extra rescue services?? at the airport.
The normal checklists were carried out and it was decided that they would exit the runway for an emergency evactuation. Because all the cabin lights been off since the situation arose, the crew were unsure of the status of the electrical system. It was therefore decided that the landing gear should be lowered earlier than normal just in case an emergency gear extension was deemed to be necessary.
Upon questioning from the controller on whether the runway should be foam covered, the captain answered that it would not necessary
(Men det ble anmodet om at bakkemannskapet måtte være beredt på kort varsel).
But it was requested That the ??must be avaiable on short notice.
Immediately before landing it was noticed that the "special smell" was becoming stronger.
Because the crew were concerned that the fire could flare up again, they decided to evacuate the aircraft on the runway. The controllers were informed on this, and a normal landing was carried out and an emergency evacutaion was intitiated through the main rear exit. The fire bridage, police and ambulance were quickly in position and the patient was driven to hostpital.
-type og reg.: Beech Super King Air B200/ LN-MOE
-year manufactured 1993
-engines: 2 X. PT6A-42
Radio channel signal?: LTR 61
Date time: 8. november 2001, kl. 1634
Position : Near Seida VOR FL210
Type of emergence: Emergency in flight - fire in cockpit
Type of flight Aerial ambulance
Weather: Clear with the ground in sight
Light status: Dark
Flight conditions: VMC
Flight plan: IFR
Total on board 3 crew + 1 patient
injuries: None
Aircraft damage Completely shattered left front window
Other damage None
Captain
-sex/age Male, 48 years
-Licence: ATPL-A
-experience: Flight time total: 4 813:30 hours, multi engine: 4 363:30 hours. Instrument total: 2 496:30 hours. Night : 1 669:50 horus. Time on type 2 150:00 timer. Time on type last 90 days: 72:05 hours, instrument time 56:20 hours, night: 22:15 hours. Total flight time last 30 days/ 3 days/ 24 hours: 32:55 hours/ 6:15 hours/ 3:50 hours. This flight 0:50 hours. Landings last 90 days: 48. Total hours since last sleep: 8:30 hours.
Factual information
The crew started the day with a flight from Kirkenes to Tromso. About over Alta at Fl260 the crew noted an unusual smell in the aircraft (it smelt most like cabbage). No smoke was observed
The medical crew searched the cabin, but could not find anything unusual. After 2-3 minutes, the smell disappeared by itself. The crew too that the smell could have come from the pateint who farted in the cabin.
The following flight from Tromso to Hammerfest went normally. At 1614, the aircraft took off from Hammerfest and set course for Kirkenes and established itself at the cruise height of FL210.
15nm west of the Seida VOR the crew again noticed the same smell they had observed earlier in the day, but now it was more intense.
Simultaneously they observed smoke in the cockpit. The procedure for smoke evacuation was begun immediately.
The crew donned oxygenmasks and at the same time the passenger oxygen was activated.
Beskyttelsesbriller mot røyk ble vurdert tatt i bruk, men fordi røyken ikke var særlig tykk eller irriterende, ble dette tiltaket ikke ansett som nødvendig.
The ?? against smoke was activated, but because the smoke was not too thick nor irritating, this was not so urgent.??
Seconds after the crew had donned the oxygen masks, 15-20cm long flames began to flicker from the lower right corner of the left front window. The first officer requested to take the fire extinguisher from under his seat and simultaneuosly the captain disengaged the autopilot and began an emergency descent.
The first officer meanwhile had difficulties with getting loose the fireextinguisher because he was not clear that it was secured with two clamps and because he had to feel his way (under his seat). He loosened the one clamp and ripped the other one right off and gave the captain the fire extinguisher. The captain handed over control of the aircraft to the first officer and began to extinguish (the fire). After the fire had flared up again three times he succeeded.
Whilst the first officer struggled to release the fire extinguisher, the Captain called Bodo kontrol and gave a mayday call with a short description of what had occurred. Because the captain was worried that the fire would flare up again, he asked the nurse to come forward with the fire extinguisher from the cabin.
The extinguisher was brought forward to the cockpit and pulled out the pin ready to use.
All electrical systems were turned off and turned on again in order to try and isolate the problem. It was clear that the fire had to stem from the heating elements in the windscreen. The switches for "Windshield Anti-Ice were then switched off. This was unproblematic as there were no icing condtions.
(It is standard procedure that Windshield Anti-Ice shall be enabled?? on the Before Taxi Checklist and remain on for the whole flight because the windows are more likely to withstand against impact e.g. birdstrike)
The Captain considered whether he should fly to Vadso instead of Kirkenes as it was 10 nm closer. But because the situation was under control, together with the fact that Kirkenes had longer runways and better rescue services, he chose to continue to Kirkenes.
In addition, they had visual contact with both airports ?? (slik at avgjørelsen lett kunne endres??).
They began to go through the points on the emergency checklist but were not finished when the heard a loud bang and saw that the window in front of the Captain had broken. 5 minutes has passed since the fire had started. Because it was nearly impossible to see through the window, the captain handed over control of the aircraft to the first officer, and at the same time reduced the speed to 170kts. The emergency checklist was completed.
They were lined up for a visual approach to runway 24. The nurse was informed of the situation. She on her side could communicate with the captain that the situation in the cabin was under control. Then Bodo control instructed the crew to contact the Kirkenes control tower.
Vakthavende flygeleder ble orientert om at situasjonen syntes å være under kontroll og at fartøysjefen ønsket på flyplassen.
The tower controllers were told that the situation seemed to be under control and that the captain wanted extra rescue services?? at the airport.
The normal checklists were carried out and it was decided that they would exit the runway for an emergency evactuation. Because all the cabin lights been off since the situation arose, the crew were unsure of the status of the electrical system. It was therefore decided that the landing gear should be lowered earlier than normal just in case an emergency gear extension was deemed to be necessary.
Upon questioning from the controller on whether the runway should be foam covered, the captain answered that it would not necessary
(Men det ble anmodet om at bakkemannskapet måtte være beredt på kort varsel).
But it was requested That the ??must be avaiable on short notice.
Immediately before landing it was noticed that the "special smell" was becoming stronger.
Because the crew were concerned that the fire could flare up again, they decided to evacuate the aircraft on the runway. The controllers were informed on this, and a normal landing was carried out and an emergency evacutaion was intitiated through the main rear exit. The fire bridage, police and ambulance were quickly in position and the patient was driven to hostpital.
Last edited by compressor stall; 6th Jun 2003 at 13:33.
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I believe that all crewmembers (flight and medical) did an excellent job under very challenging and near fatal circumstances. This also demonstrates excellent CRM, i.e. use all resources available to you.
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Thanks, Compressor Stall. It makes a lot more sense with your translation of the report at hand. Indeed well done to the crew. Good CRM and good thinking, but the FO nearly unable to get the extinguisher is food for thought. Ours are positioned so we can see the clamps, makes it a lot easier to use them..
I suppose the emergency checklist has been amended to cover "funny odours"?
I suppose the emergency checklist has been amended to cover "funny odours"?
