The bad smell that won’t go away

Air Berlin has admitted it suffered a cabin air contamination event on an Airbus A330 flight from New York JFK to Berlin, and that it has had to report it to the investigator, the BFU.

The crew reported smoke and a “wet pullover” smell in the cockpit and cabin during climb and again during descent. They also report feeling variously dizzy, sick, and suffering numbness in their fingertips. Having reported to base by ACARS and satphone, they got a strange response from the airline’s medical department: they could give no advice on cabin air contamination because such events were “political”.

The airline, in its statement about the event, makes much of its dutiful action in reporting it to the authorities. Actually It had no choice, because people on board suffered medical consequences, which makes reporting compulsory.

Cabin air contamination events are widely ignored by all airlines as inconsequential, and they avoid reporting them if they can, but in this case (25 September) the crew had to receive hospital attention on landing, and the Purser was detained there for two days.

This event, like all the others, was caused by engine oil fumes entering the cabin bleed air feed because of an engine oil seal leak. Upon landing the technical staff reported visible oil leakage on the spinner and in the engine casing. 

It is well documented (not least by Flightglobal and Flight International) that these events cause pyrolised organophosphates, particularly tricresyl phosphate (TCP), to enter the cockpit and cabin. TCP is a neurotoxin that has caused many crew all over the world to lose their health and, as a result, their pilot licences or their ability to function as cabin crew.

Air Berlin has strenuously avoided answering Flightglobal’s question as to whether it has warned the 262 passengers of the risk to their health. Actually there is no treatment for organophosphate poisoning, so it could be argued that there’s no point in telling them. But at least they would know what might have caused a sudden deterioration in their general health and where to go for reparation. That, of course, is another reason not to tell them.

Finally, by not telling the passengers, Air Berlin would be doing no wrong according to the law, because the aviation agencies, including EASA, have strenuously avoided getting involved in the passenger and crew health aspects of bleed air contamination on the grounds that passenger and crew health is not their business. Cabin air contamination has not yet caused a crash. It nearly has, as the UK Air Accident Investigation Branch has reported, but not quite. The almost-incapacitated crew managed to land the aircraft.

The solution? Pilots should put oxygen masks on immediately they smell fumes. So that’s all right then.

So, after a fume event, all the airlines have to do is to is report it, repair the oil seal and go on as if nothing has happened until the next time.

I wonder how many European passengers know that the aviation authorities say that passenger and crew health on board public transport aeroplanes is of no concern to them?

4 Responses to The bad smell that won’t go away

  1. Captain David Zaharik 7 October, 2011 at 3:50 pm #

    David

    The oxygen mask is indeed the only mechanism to protect the pilots, but how many pilots are there that know what the smell actually is? I suspect very very few… in fact I know so.

    I have developed a health information bulletin that clearly delineates procedures that pilots should follow. Step one is don the oxygen mask, two, check your crew (pilots and flight attendants). Both my airline and my union have had the bulletin for several months and still not distributed it.

    My focus in the bulletin is toward the pilot. Dead pilots mean dead flight attendants and passengers. Sick pilots mean endangered flight attendants and passengers.

    “Safety delayed is Safety denied”

    After the Cranfield workshop next week, I will up date any new information and make the bulletin available to all… perhaps you would like to publish it?
    Cheers

  2. David Connolly 10 October, 2011 at 11:11 am #

    Gott in Himmel Herr Learmount !, don’t lose the faith. What AF447 has done for LOC awareness, AB7249 could do too for TCP- CFC(Cabin Fume Contamination) awareness. Hypoxic is bad enough, like taking off with the packs off , as did Aer Lingus Flight EI840 B-735, from Cork to Amsterdam on Dec 7 2000. The AAIU’s stated cause was thus : “Failure of both flight crew members to complete and confirm their “After-start” and “After take-off” normal checklist for air conditioning and pressurisation and the lack of a thorough analysis of the initial “Auto Fail” and “Cabin Altitude” warning, caused the aircraft to be operated without pressurization”. This was a very near disaster, by all metrics, largely prevented by the leading cabin crew member/purser repeated questioning of and complaining to the flight crew who finally stopped the asent. That then Captain is flying as an A-330 F/O to this day, with the same airline. This was a precursor to Helios Airways Flight ZU522 B-733,on August 14 2005 from Larnaca to Athens killing all 121 on board. Hypoxia is indeed very insidious, not unlike the scuba hazard of nitrogen narcosis-raptures of the deep, Martini effect. Air Berlin has previous TCP events involving an A-332 on three occasions in April 2011. And lets not forget Germanwings Flight 4U397 A-319, from Dublin to Cologne on May 27 2008. The crew and pax reported similar symptoms to AB7249. AB7249 has the advantage of volume of victims, duration of flight and potential US litigation exposure to focus minds above other events due to its unique willful recklessness of being a de-facto test flight with involuntary pax and crew guinea pigs.
    TCP -Hightoxia is perhaps the silent elephant man in the room with a pungent odour, that all avert their gaze from. It certainly never entered my mind until relatively recent coverage on Learmount’s Operationally Speaking Blog. Bleed valves and pack valves were always the previous concern of being in, on and open after takeoff, but I guess after 50 years and increased frequency and knowledge of toxicity, aviation bleed air has reached the inflection point that asbestos did for building and shipping construction. Conspicuous by its absence in your analysis is the fact that having suffered a clear and present toxic event with multiple physical witness symptoms, exhibiting-at best- partial incapacity, that the Captain thereafter decided to continue to climb from 2500ft to FL380. Therafter to cruise across the Atlantic ocean, inviting the possibility of losing an engine or both due to lack of oil seals thereby conducting a de-facto EToxicOPS test flight with involuntary pax and crew guinea pigs. For potential risk, remember Eastern Airlines Flight EA855 L-1011 Tristar, on May 5 1983. To wit :Eastern Air Lines Flight 855 took off from Miami International Airport at 08:56 on a flight to Nassau International Airport in the Bahamas carrying 162 passengers and 10 crew. At 09:15, while descending through 15,000 feet, an indicator lit to warn of low oil pressure on the TriStar’s #2 engine. This engine was shut down by the flight crew. Due to the worsening weather conditions over Nassau the crew elected to return to Miami to land, and received a clearance back to Miami, as well as instructions to begin a climb to FL 200.
    En route back to Miami, low oil pressure lights for engines 1 and 3 illuminated. At 09:28, at an altitude of 16,000 feet, engine 3 flamed out. At 09:33, engine 1 flamed out. While the flight crew attempted to restart engine 2, cabin lights went off and flight deck instruments stopped working. The aircraft descended without power from about 13,000 feet to about 4,000 feet, at which point the crew successfully restarted engine 2 and executed a landing at Miami. None of the 172 passengers and crew aboard was injured in the incident.
    The NTSB determined that the probable cause of the accident was “the omission of all the O-ring seals on the master chip detector assemblies leading to the loss of lubrication and damage to the airplane’s three engines as a result of the failure of mechanics to follow the established and proper procedures for the installation of master chip detectors in the engine lubrication system, the repeated failure of supervisory personnel to require mechanics to comply strictly with the prescribed installation procedures, and the failure of Eastern Air Lines management to assess adequately the significance of similar previous occurrences and to act effectively to institute corrective action. Contributing to the cause of the accident was the failure of Federal Aviation Administration maintenance inspectors to assess the significance of the incidents involving master chip detectors and to take effective surveillance and enforcement measures to prevent the recurrence of the incidents.”
    The Captain of AB7249 was possibly a very early promotion from the right seat, if not a nepotistic parachute promotion into the left seat-a non-diversion corporate yes man or woman. His/her demonstrated reckless operation and dereliction of duty of care was aided and abetted with Air Berlin’s abrogation of responsibility of duty of care . To find a historical parallel of reckless operation brought to the present legal day, look no further than the Captain of Luxair’s Flight LG9642 F-50, from Berlin to Luxembourg crash on November 6 2002. He was the fast track son of Luxair’s chief pilot and survived along with one pax. The 20 others on board did not, including his hapless ignored F/O. He is on trial, among others, at the 9th Penal court for assumed sentencing in Luxembourg on Oct 10 2011.The Asian parallel of that is Air China Flight CA129 B-762, from Beijing to Busan-Korea on April 15 2002 killing 128 of 167 in a CFIT. The Captain survived that too, not including his hapless ignored F/O either. Literally, same movie, different cinema, similar METAR as Luxair. Air China and Luxair addressed various toxic political/operational CRM crew culture issues as a result of these own goals. For China in general and Air China in particular, I can say with confidence, lessons have been learned and inculcated into the culture. Of course law is always lagging and looking aft long after the lessons were learned. Unfortunately it took the tombstone imperative to force cultural change.
    Another highly questionable technical continuation was British Airways Flight BA268 B-744, from Los Angeles to London Heathrow on Feb 19th 2005, when engine #2 surged shortly after take off, the crew continued across the United States instead of diverting to a BA station like Chicago or New York, affording ample time to source a spare powerplant or hotel accommodation and traversed the Atlantic ocean, as a de-facto endurance test flight but then had to divert to Manchester, with the crew declaring emergency because of the possibility to land below required final fuel reserve. What if Manchester turned CAT III and the localizer line was stretched out past endurance ‘s?

    That flight continuation had sparked substantial controversy, but was not disapproved by the UK’s AAIB in their final report. This was-in my view-reckless operation. The report however stated, that the windmilling of the engine without engine oil supply over an extended period of time increased the damage to the engine and thus posed the danger the engine could seize. The AAIB therefore recommended that the FAA and other regulators “should review the policy on flight continuation for public transport aircraft operations, following an in-flight shutdown of an engine, in order to provide clear guidance to the operators.”
    Air Berlin’s attitude of calling toxic poisoning a “political” and not a medical issue and trying to spin dereliction of duty to dutiful obligation is , well, breathtaking-literally. And is in effect inviting a tombstone imperative. If it was Air France, like AF7249, I would not be too surprised at their attitude, considering their abrogation of responsibility from the spectrum of carnage from the Concorde to AF447. Air Berlin’s attitude seems if anything, anti-German in a cultural sense of taking charge of responsibility and avoiding scapegoating, since WWII, they have generally been very proactive in being transparent. For customer care, Air Berlin’s AB7249 PR SOP makes Ryanair look like Emirates. It certainly illustrates that PR is the inverse square root of all BS too.
    As for EASA ?, they are so inept that they call CRM, MCC. A crew is Multi, BY definition and Cooperates BY definition. Only a Eurocrat could come up with the utterly moronic oxymoronic MCC/Multi Crew Cooperation, still it always makes me laugh. A pilot is singular, a crew is plural. If they can’t define that, it is hardly surprising that they view TCP as the bleeding obvious political rather than medical.
    Henry Kissinger, ex-US Secretary of State under Nixon said he did not know who to call, if he had to call Europe, plus ça change, plus c’est la même chose, and Henry was German-ironically. The best example of the EU’s two legged dog’s dinner is Catherine Ashton, Baroness Ashton of Upholland Lancashire UK, a British Labour politician. Her Highness is naturally an unelected Tony-Crony, who in 2009 became the European Union’s High Representative of the Union for Foreign Affairs and Security Policy. Yes really, apparently it is not parody, but certainly landed long beyond it. Under the Lisbon Treaty this post is combined with the post of Vice-President of the European Commission. This is primarily why I voted NO to this piece of Euro-trash, singular and plural, in Cork on June 12 2008. As that vote was treated with SOP Euro contempt, I did not vote correctly the second time. One has to ask, her Highness, the High Baroness is bureaucratly high, politically high, narcoticly high or perhaps from her EU air miles, TCP high ? and suffering from dizzying vertigo from the EU’s rotating presidency ?. I mention this muppet show to illuminate your surprise at the EASA’s lack of concern and therefore lack of action, look at it’s EU-EC’s DNA, if only the commission omitted more and committed less, when contrasted with the FAA’s more robust concern and penalty action, to the point of overreaction. The middle ground between these two extremes is, alas, the top and bottom of the Atlantic ocean.
    This issue is being industry led-thankfully, with Boeing’s bleedless B-787. Regulation did not require them to take such a path, long term economics did and will prove thus, I was never surprised at the nightmare delays. For the current global fleet, industry will lead too. If we were relying on regulation as a solution we would be long dead. Remember that regulation from A-Z is now and forever shall be, public comfort and political vindication. Boeing, Airbus, P&W,RR and GE and operator customers can lead the way towards failing better in future. Regulation only ever looks back and past is not prologue, but a best practice guide to epilogue.
    You expressed apparent surprise at the EASA’s cavalier nonchalance. Wake-up please, you are old enough and qualified enough to know better. EASA stands for European Air Safety Agency. What does that tell you ?. What it tells me, is that, if an agency’s function-that is usually implicit-has to be stated EXPLICIT, then it is neither. For example, the Federal Aviation Administration and the Civil Aviation Administration of China, FAA & CAAC respectively are explicitly that. They administer with a delicate balance of conflict of interest between promotion and regulation. But IMPLICIT in their Administration’s modus operandi-modus vivendi is draconian authority and punitive penalty for administrative regulatory transgression, with a penalty spectrum of fine to license suspension/revocation to refer to jurisprudence. FAA & CAAC=PDQ-QED!…Perhaps when the EASA evolves to a EAA, as in European Aviation Administration, it will evolve into an implicit and credible safety agency. It has great potential, but I won’t hold my wheezing, spluttering TCP breath.
    At least there is progress on another toxic air EU issue, namely the EU’s Emissions Taxing Scam. China fired the first econ salvo for a possible ETS trade war at Le Bourget on June 24 2011 by basically cancelling Hainan Airlines A-380 order. Unlike the EU, the Communist Party of China (a nom com holding company of 77 million voting members) of the PRC can actually make decisions-albiet, non general democratic but CPC particular democratic. And China is a Mecca of A-Z production pollution, so they are in no mood to takeaway the EU’s Perpetual BS variety, life really is too short. And the ever present Sun Tzu died in 496 BC, China Hand-Sir Percy Cradock, GCMG died on Jan 22 2010 AD. The EC could commit itself to read their works and do something useful, just for a change. The EU’s EASA was established in Cologne on September 28 2003. As a work in progress, it shows potential, but alas on TCP it cannot or will not see the wood from the trees and has been found wanting. Toxicity comes in many forms, chemical, political, economic or all three. And if the EASA is too lethargic to be apathetic, let’s hope it soon evolves into a proactive EAA, but I won’t hold my breath, as I said.

  3. Harald Stephansen 24 October, 2011 at 2:26 pm #

    As noted by Mr. Connolly, Boeing may solve this problem by their bleedless configuration of the new 787. It is however nothing really new. Back in the 1950s there were concerns about using bleed air for cabin pressurization and the DC-8 came with a system of bleed air driven cabin compressors. These compressors were fed outside air through the airscoops below the cockpit to ensure uncontaminated air in the cabin. The reason was doubts about the ability of engine oil seals to keep oil or fumes from entering the bleed air. This system, which I also believe was used on the 707, worked. However it added weight = cost and, as always, promises of better economy won over safety concerns in later aircaft designs.

  4. David Connolly 3 November, 2011 at 2:32 pm #

    I remember that on the B-707, the cabin compressors are located on the No#1, 2 and 3 engine pylons. And as bleed air has reached its zenith, the B-787 is taking us back to the future. And as the B-787 will be the iPhone of aviation, it is past time and better late than never in going back to the future.