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-   -   Toxic fumes incapacitate Germanwings crew (https://www.pprune.org/rumours-news/496660-toxic-fumes-incapacitate-germanwings-crew.html)

txl 28th Sep 2012 09:56

Toxic fumes incapacitate Germanwings crew
 
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 (PDF)

Kerosene Kraut 28th Sep 2012 10:17

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 28th Sep 2012 11:06

Airbus 'nearly crashed' when pilots fell ill - The Local

txl 28th Sep 2012 13:18

Media allege cover-up
 
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 28th Sep 2012 14:11

Similarities
 
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/4...ded-dizzy.html

lomapaseo 28th Sep 2012 14:18

and the passenger :confused:

Loose rivets 28th Sep 2012 14:24

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

txl 28th Sep 2012 18:10

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 28th Sep 2012 18:23

Autoland not an option ?
 
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 28th Sep 2012 18:42

One engine for the flightdeck air only?

Annex14 28th Sep 2012 19:15

LR and lomapaseo
 
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 28th Sep 2012 22:32

Oil fume exposure medical protocol
 
This will help anyone who has been exposed to oil fumes whilst flying:

Medical information

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:


Annex14 29th Sep 2012 18:25

TCP
 
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

mickjoebill 30th Sep 2012 06:23


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 30th Sep 2012 08:05

mickjoebill
 
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

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 30th Sep 2012 08:35

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

OldBristolFreighter 30th Sep 2012 08:58

Why only L.H. failures?
 
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 30th Sep 2012 09:04

Why only on LH ?

and why only a cockpit became a Gas-Chamber ?

hetfield 30th Sep 2012 09:34


Why only on LH ?

and why only a cockpit became a Gas-Chamber ?
Source LH Engine/Pack?

B737NG 30th Sep 2012 12:11

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

Machinbird 30th Sep 2012 15:27


Originally Posted by 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.

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, I picked up the following paragraph:

TCP's mechanism of action is similar to other organophosphates in that it can inhibit the enzyme acetylcholinesterase, leading to a buildup of 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 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 1st Oct 2012 09:25


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 1st Oct 2012 10:35


Originally Posted by 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.

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 1st Oct 2012 11:00

ITF Campaign
 
Here the link to the new ITF campaign on cabin air quality.
International Transport Workers' Federation: Aircraft air quality

hetfield 1st Oct 2012 11:43

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 2nd Oct 2012 12:07

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 3rd Oct 2012 10:30

Recent developments
 
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 3rd Oct 2012 15:29


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 3rd Oct 2012 17:40

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 3rd Oct 2012 22:37

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 4th Oct 2012 08:45

TCP developments
 
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
and
DER SPIEGEL*9/2011 - Gestank alter Socken
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 4th Oct 2012 08:57


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 4th Oct 2012 09:16

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 4th Oct 2012 12:15

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.


Originally Posted by Gestapo
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 4th Oct 2012 13:13

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

lakerman 4th Oct 2012 13:30

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 5th Oct 2012 07:59


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...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 5th Oct 2012 09:02

call me skeptical
 
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 5th Oct 2012 19:55

@cwatters

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

zerograv 5th Oct 2012 20:25

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?


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