Following the copilot's collapse with nausea from oil fumes in the cockpit air on an Air Berlin flight from Milan Malpensa to Dusseldorf in November, German accident investigator BFU has taken the unprecedented step of sending a blood sample from the copilot for analysis to a specialist scientific organisation.

Loss of control in big jets is a problem that has had the industry wringing its hands for years. 

The crew of an Airbus A300-600 at London Gatwick found the slats/flaps wouldn't deploy correctly after start-up, so they recycled them several times, following procedures in the QRH, and talking to their engineering base.

On 20 December a British Airways Airbus A321 flight from Heathrow to Glasgow suffered a serious cabin air contamination event.

During the European volcanic ash grounding in April 2010, EasyJet's head of engineering Ian Davies began to wonder if there was a better way, so he googled volcanic ash and emerged with a name: Dr Fred Prata of NILU, the Norwegian Institute of Air Research.

Dr Fred had been working for years on systems for tracking volcanic ash by satellite and was probably the world's foremost expert on it, so Davies hit the jackpot first time. But Dr Fred was also working on developing an aircraft-mounted infra-red ash sensor, called AVOID, that could provide pilots with a display a bit like a weather radar showing them where the worst ash was so they could avoid it. At FL200 it can see ash about 100km (54nm) ahead. Airbus will soon be joining the trials to provide the high-altitude test capability.

Ian decided EasyJet should get involved, because someone had to. He found out that Dr Fred knew a whole load of stuff that could have made April 2010 a relatively benign event, but nobody was listening to scientists then, least of all to Fred. It took Eyjafjallajokull to wake the authorities up. They are listening now.


Despite the sophisticated nature of the trials, the airstrip at the base of Etna that we were operating from on 6 December - Calatabiano (near Fiumefreddo north of Catania) - was charmingly basic.

 EZY provided us with a chopper to chase the ultralight on its mission.
...so we did, and this is what we saw...

That's Etna in the background, covered in cloud. Not the best day for seeing everything.


...But (above) the eyebrow window's tinted glass cuts out the glare so you can see where the ash is.

And here's a helicopter view of our return to the aerodrome...
But what's it all for?
That's the AVOID pod. It's very expensive, making it rather unlikely that airlines will choose to fit it. But EZY is going to fit it to 20 of its A320 series fleet, and it hopes other European carriers will fit about 80 more to aircraft based around the continent. If they do, this exercise  will achieve much more than just providing tactical avoidance capability to the airframes actually fitted with AVOID.

When the next ash event happens, the crews of these aeroplanes can send back pireps telling ATC where stuff actually is. This enables comparisons to be made with the predicted location of the various densities of ash, so the predictive algorithms can be refined, and the accuracy of the surveillance picture provided by satellite sensors and ground-based lidar stations can be checked in reality.

The whole exercise is about building confidence in the total system, and continually adding to the knowledge base. So when Katla blows its top, we know how to react.

Well done EZY, Dr Fred Prata, NILU, and Prof Konradin Weber of Dusseldorf University.

In fact the whole team...

On 15 November the Independent Pilots Association launched a campaign to attract British Airline Pilots Association members. The IPA was capitalising on discontent among BALPA members about the latter's handling of two disputes over the last three years.

The first was BALPA's dispute with British Airways over terms and conditions at its Open Skies subsidiary, which resulted in an expensive and comprehensive defeat for the union. BALPA's excuse is that it received poor legal advice. But Flightglobal has copies of the legal advice, and it reads like a firm statement from the union's lawyers that there were no grounds in law for the demands BALPA was making of BA, so the decision to proceed looks reckless.

More recently a dispute over conditions at Virgin Atlantic, about which members felt so strongly that they were prepared to strike, fizzled out when BALPA surprised the members by advising them to accept a company offer with which they were unhappy. Secretary general Jim McAuslan said the deal was "in the long term interests of the members," but Virgin pilots have told Flightglobal that they think the union secretariat are "so busy looking after themselves" that they don't listen to the membership. McAuslan admits there is a review ongoing about how the Virgin dispute was handled.

Meanwhile the final settlement with BA is imminent. It is likely to cost the union about £1 million.

McAuslan told Flightglobal that BALPA's job was not only to listen, but to lead, remarking that trying to win consensus was "like herding cats". He says that, following a recent survey of members' views about the union, which was broadly - but not by big margins - favourable, BALPA will be acting more as a unified organisation rather than as a federation of pilot councils at individual airlines.

BALPA has a long history and a strong brand name, but its leadership hasn't been effective for some time. Maybe the current IPA bid to take over the representation of Britain's pilots is a timely warning to McAuslan and his team.

This video demonstrates why helicopters have a high accident rate relative to fixed wing.

 

The pilot clearly didn't anticipate this outcome. Fortunately he survived it, and so did the people nearby, who could also have been killed by high velocity debris.

Let's examine the decisionmaking processes that preceded this event.

Look at the space in which the helicopter was operating. Making a sound decision about whether or not to operate there entails understanding the principles of risk management, but most pilots are not trained in it.

Neither, by and large, are the decisionmakers who run small helicopter operations.

Relatively recently, some fixed wing pilots on MPL (multi-crew pilot licence) courses have begun to be taught threat-and-error-management as a part of their training, but that is not widespread.

A mission risk level can be calculated by multiplying the level of risk (on a 1 to 5 scale) by the seriousness of the potential outcome if the worst happens.

In this case the risk of hitting an obstacle was at least 4 but probably 5, and the outcome from hitting it (total loss of helicopter, high risk of death or injury to pilot and people on the scene) is definitely 5.

25 is a big number on this scale, so don't do it. The job can be achieved by some other means.

I have just come back from the International Helicopter Safety Seminar at Fort Worth, and I reported as follows in Flight International: "The top global industry problems, according to International Helicopter Safety Team data analysis, are the lack of a risk management culture at operator level, and poor pilot judgement when an accident situation develops."

So what we have just witnessed is not a one-off, it's endemic.

The Flight International report continues: "Analysis reveals that the top solution to poor helicopter operator safety performance is the adoption of low-cost flight data monitoring (FDM) systems, coupled with training tailored to correct the problems revealed by the FDM." So when pilots make bad decisions but get away with it, you know, and can do something about it.

"Having developed this analysis, the IHST's top problem, according to FAA IHST representative Sue Gardner, is how to get these messages out to the small operators which represent more than 80% of the industry."

Back in 2008, in a Comment article in Flight International, we discussed a research task that Cranfield University had been given. I quote:

"Commissioned by the UK Department for Transport, Cranfield University is carrying out scientific tests to establish what contaminants are occasionally released into airline cabins in the engine bleed air feed to the air conditioning system.

"The purpose is to establish...what the contaminants are. It is not Cranfield's job to test what effects these have on crew and passengers. That is being done elsewhere.

"The DfT has a duty beyond that of Cranfield's very able scientists. It has to look at all the other evidence that has been gathered from multiple sources over decades, and it has manifestly not been doing this.

"Cranfield's resources are limited. They have five aeroplanes on which to carry out tests, and only 20 trips each. If they get no contamination events, or only low intensity ones, what then? Will they be able to project credible conclusions on this evidence alone?"

End of quote.

That job Cranfield took on was the figurative poisoned chalice. I used those words to the late Dr Helen Muir when I heard she had been tasked with leading the Cranfield team who were to carry out the tests. We were at a Flight Safety Foundation seminar where she was being presented with an award for her groundbreaking cabin safety research.

Muir was a Cranfield academic for whom I have huge respect, and I am among thousands in the aerospace world who share admiration for her work. She died well before publication of these test results. 

The report's conclusions were uncharacteristically weasel-worded. In fact they were not conclusions at all. Not according to the dictionary definition of that word anyway. You will see in a moment what I mean.

Now a Cranfield University professor, head of the University's nanotechnology department, has taken up the baton.

On 11 September, on Cranfield's campus, Prof Jeremy Ramsden chaired an international, multidisciplinary workshop backed by Swiss independent research organisation Collegium Basilea. The subject was Inhalable Toxic Chemicals in Aircraft Cabin Air.

This is what he had to say about Cranfield's work for the DfT: "This report actually found significant concentrations of organophosphate neurotoxins and other noxious substances in cabin air even under normal flying conditions.

"Unfortunately," said Ramsden, "the final conclusion of the report is the statement: 'With respect to the conditions of flight that were experienced during the study, there was no evidence for target pollutants occurring in the cabin at levels exceeding available health and safety standards and guidelines.'

"The first phrase underlines the fact that the study failed to achieve measurement of a 'fume event', even though that was one of its principal objectives. Even for 'normal flying conditions' the purported conclusion is irrelevant because no standards are available for some of the most problematical substances. Nevertheless, despite the fact that this 'conclusion' is neither sound nor justified by the actual work carried out, it has been carelessly and uncritically quoted, including by the UK Minister for Transport Theresa Villiers, and widely used to infer that there is no safety and health problem."

Ramsden also said what he thought should be done about this situation. He added:

"The mandatory inclusion of a health warning on air tickets, as on cigarette packets, would seem to be the alternative in the face of technical inaction."

If you want to find out more, enter the word "toxic" or "cabin air contamination" in the search box for this blog and you will find plenty more material. 

Much as Qantas' Capt Richard Champion de Crespigny has praised the A380's ability to absorb massive damage and still fly safely, he says the Australian Transport Safety Bureau will provide Airbus with plenty of food for thought when it publishes the report of its investigation into the QF32 engine failure event in November last year.

It's not clear how soon publication will be, because the damage caused by the catastrophic uncontained engine failure was so extensive, and the A380 and its systems are so complex, that the primary effects of the damage would fill a thick book, but the secondary and tertiary effects could keep the ATSB busy for a lifetime if it became fixated in detail.

De Crespigny refuses to break protocol by revealing what he knows in advance of the report. But having said that, the report is scarcely going to be a surprise for Airbus, which is assisting the ATSB in the investigation, as manufacturers are obliged to do.

Some changes in the pipeline are already clear. One of the particular problems de Crespigny and his crew faced that day was the plethora of ECAM alerts: more than 60 of them.

In future, when the system is faced with multiple failures, the ECAM display will now state how many alerts there are. For example, the first of the electronically prioritised alerts on QF32 would have been labelled "No1 of 60", which would have enabled de Crespigny to decide more quickly than he actually did that this was a situation in which ordinary checklists didn't apply.

When De Crespigny realised this, he then chose to apply a reverse logic: rather than sticking to the convention of identifying and dealing with the problems (unless one of them is a fire or something that needs instant attention), the priority becomes one of  identifying and protecting the systems that are still operating.

Talking about reports, de Crespigny is writing a book. After all, Sully Sullenberger did after the Hudson River ditching, and Peter Burkill published after BA38 crash-landed at Heathrow. All three were "black swan" accidents: that is, they were caused by events that could not have been foreseen and for which there were no checklists or laid down procedures.

I have the impression that de Crespigny is thinking of filling the market space left by the fact that Handling the Big Jets (D.P. Davies), an iconic book published in 1968, was not updated beyond the early 1970s.

Things have certainly changed since then.

My colleague Max Kingsley Jones, editor of airline business, has also addressed the issue of crews being swamped with an excess of information in emergency