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Whilst investigations continue into the circumstances of tragic accident to the Helios Boeing 737 crash of last month in Greece, it is important that the investigators look into all aspects of the investigation WITHOUT being influenced by interested parties such as Boeing.
The question in everyone's mind is how were the pilots incapacitated.
Some tell us that the aircraft may have been only slightly pressurised as the crew are reported to have taken off in 'Manual' mode instead of 'Automatic' with the controller in the 1/3 open position and hence it is hypoxia that caused the crew to become incapacitated however this story does not appear to be the full truth but may be a convenient way to blame the pilots rather than accept what is an industry cover up.
All commercial jet aircraft have a cockpit warning system which warns the pilots when the aircraft internal cabin pressure reaches 10000ft. Maximum cabin altitudes on commercial jet aircraft can reach about 8000ft so at 10000ft the flight crew have enough time to cancel the aural / visual warnings and deal with the problem and this is why 10000ft was accepted as a sensible point to warn the crews.
It is reported that on the Helios flight the crew were ALREADY incapacitated by the time the cabin altitude reached 10000ft as the warning was never cancelled by the crew as is standard practice to do so. So how is this possible and what could have done this ?
It is reported by other Helios crew that the crash aircraft had a history of 'Strange Smells'. Strange smells on commercial jet aircraft are usually linked to a CONTAMINATED AIR SUPPLY, so what could have contaminated the air to produce the smells and what effects could it have ?
The air being breathed by the pilots and flight attendants WHICH IS NOT FILTERED FOR TOXIC FUMES could have been contaminated by electrical fumes due to wiring problems or by engine oils and hydraulic fluids. This has been known for over 30 years in the airline industry and yet there are NO contaminated air detection systems fitted on commercial jet aircraft!
We are aware of many previous examples of pilots becoming incapacitated due to exposure to invisible oil and hydraulic fumes, we and the industry are also aware of many serious flight safety errors where crews have made serious flight safety errors due to contaminated air.
Boeing, Airbus, British Aerospace and other manufacturers all know about this problem but like the early days of smoking, many in the industry choose to deny the issue or do all they can to cover the issue up. Crews around the world often experience contaminated air and do nothing to protect themselves out of ignorance or fear of being seen as a trouble maker.
In 2000, following a double crew incapacitation, the Australian Senate completed a year long inquiry into these matters and concluded crews WERE getting sick and that flight safety WAS being compromised.
Since then, in 2000 the Canadian Transport Bureau Interim report on Swissair 111 accident, stated:
"…recognition that within the aviation industry there has been belief that odours are often a non event diminishing concern about minor odours."
British Aerospace who have known for over 20 years of contaminated air problems on the BAe 146 stated a few years ago in an engineering Service Bulletin (number SB 21-150):
"In the past oil leaks and cabin/flight deck smells and fumes may have come to be regarded as a nuisance rather than a potential flight safety issue. However whilst investigations are being carried out to determine the nature of any agents that may be released into the cabin environment and to define any necessary corrective actions, oil leaks and cabin flight deck smells must be regarded as a potential threat to flight safety not just a nuisance."
The Australian Safety Board (ATSB), the British Air Accident Investigation Branch (AAIB), The Swedish Air Accident Investigation Branch etc… all know about these issues and have done for many years but manufacturers and airlines fail to take adequate action to protect passengers and crews.
Below are some examples from the UK alone where crews have been incapacitated due to fumes but the same reports exists in all countries. It may well be that on this sad occasion it has had tragic consequences but we were warned…..
Former Australian BAe 146 pilot Mr Nevan Pavlinovich stated in the AOPIS documentary: 'Contaminated Air: An Ongoing Health and Safety Issue' in 2003 that:
"if there is an accident it won't be an accident, as everyone knows about it!".
The Greek coroner Mr Kotsaftis tells the media that the dead pilots had no carbon monoxide poisoning so there was no contaminated air. The industry knows that you frequently get contaminated air with no carbon monoxide!
The oils crews are breathing contain organophosphates which are neurotoxins which the United States Air Force previously warned were dangerous when inhaled!
The accident investigation should be part of an open public inquiry and not allowed to be another industry cover up where pilots are blamed for errors when they became incapacitated due to an industry in denial of what is a serious health and safety issue.
For more information visit www.aopis.org or Sally at sally@aopis.org
EXAMPLE OF UK CREW INCAPACITATIONS
A/C Type : BAE146 Occurrence Number : 199900440
Flight Phase : Cruise Occurrence Date : 21 Jan 1999
Classification : Occurrences Location :
Events : Other Occurrence Location Info :
Pretitle :
Flight deck crew incapacitation - possibly due to fumes on flight deck.
Precis :
During cruise at FL240, P2 reported blurred vision, tingling in fingertips & a lack of concentration & requested that P1 assumes control. P1 noted that P2's face was white with lips discoloured & pupils dilated. Pressure checked satisfactory but P1 ordered P2 to use oxygen, then almost immediately P1 felt light-headed with tingling in fingertips. "Smoke in cockpit" drill & high speed descent initiated - ATC informed. Nr1 cabin crew member called to flight deck & reported no smells or fumes in cabin but an almost imperceptible smell on flight deck. Cabin monitored for remainder of flight with no problems noted & with only faintest decreasing smell on flight deck. A/c landed safely with no further incident & flight deck crew were taken to hospital as a precaution. See also 99/02108. Initial report from manufacturer suggested that the most probable cause of the incapacitation was due to the use of dry ice. The Medical and Dangerous Goods Officers 'are sceptical of the above cause' and further consider that the ingress of mineral oil fumes is also unlikely; this is also supported by a research paper from the Dept of Health Care and Epidemiology - University of British Columbia. The operator is no longer using the particular brand of dry ice and has revised his procedures with regard to the stowage of chilled containers immediately adjacent to the flight deck. It seems that there is no conclusive evidence as to the cause of this incident. See also 2000/08340 and other related occurrences contained therein.
CAA Closure: Hazard adequately controlled by existing procedures.
A/C Type : BAE146 Occurrence Number : 200008340
Flight Phase : Flight Occurrence Date : 05 Nov 2000
Classification : Serious Incidents Location : Birmingham
Events : Smoke / Fumes (not engine)
Crew Illness / Incapacitation
A/c Technical Occurrence
APU Fire / Failure Location Info :
Pretitle :
Serious Incident : Oily fumes inside aircraft due to leak from APU. P2 incapacitated and P1 performance impaired. AAIB Formal investigation.
Precis :
AAIB Aircraft Accident Report 1/2004 - Summary: The incident occurred whilst on approach to Birmingham Airport. Following reports of unusual "oily petrol" smells in the cabin, the first officer, after visiting the cabin, started to feel nauseous. The first officer's condition began to decline to an extent that he had difficulty in concentrating. The commander took over the handling duties and the first officer went onto 100% oxygen, and took no further part in the flight. The commander also felt "light headed" and had difficulty in judging height during the ensuing approach and landing. Following a successful landing, the commander was able to taxi the aircraft and began to feel better. The first officer and commander were taken to hospital and examined, but no abnormalities were found. An engineering investigation revealed the presence of an oil leak from the auxiliary power unit (APU) generator cooling fan seal, which allowed engine turbine oil to enter the APU air inlet plenum chamber and, subsequently, fumes to enter the cabin via the Environmental Control System (ECS). During the investigation, further incidents involving other aircraft types were reported. Therefore, the scope of the investigation was widened to include these other incidents. The following causal factors were concluded during the investigation: 1) There is circumstantial evidence to suggest that the flight crew on G-JEAK were affected by contamination of the air supply, as a result of oil leakage from the APU generator cooling fan seal into the APU air stream, and into the ECS system ducting. This contamination allowed fumes to develop, a proportion of which entered the cabin and cockpit air supply. 2) Subsequent research and tests suggests that the crew of G-JEAK, and the crew of other aircraft which have suffered similar incidents, may have been exposed to turbine engine oil derived fumes in the cabin/cockpit air supply, originating from either an engine or APU, which had irritant, rather than a toxic effect. Five safety recommendations (2001-04 to -07 and 2001-47) were made during the course of this investigation.
CAA Closure: CAA FACTOR F12/2004, detailing the CAA responses to the five AAIB Safety Recommendations, was issued on 20 February 2004. Any further CAA action required will be progressed via the 'Annual Review of AAIB Recommendations' procedure.
A/C Type : BAE146 Occurrence Number : 200008834
Flight Phase : Initial Climb Occurrence Date : 09 Nov 2000
Classification : Occurrences Location : Belfast City
Events : Smoke / Fumes (not engine)
Crew Illness / Incapacitation
Engine Malfunction Location Info :
Pretitle :
Fumes on flight deck and in cabin. Recurring fault. Crew felt unwell.
Precis :
Just after take-off, strong smell of fumes noted on flight deck when engine air selected on and APU air selected off. Smell dissipated after approx 90 seconds and with no smell reported in pax cabin, flight continued and situation monitored. Remainder of flight uneventful except that both pilots experienced some mild eye irritation. During turnround (with APU running and APU air/air conditioning packs 1 and 2 selected), when Re-circ/Fresh switch selected to Re-circ, a strong smell of fumes filled flight deck and forward section of cabin, although no smoke visible. Flight deck fumes appeared to emanate from side console vents adjacent to cup-holders. Vents closed, Re-circ switch selected to Fresh which seemed to alleviate problem and flight deck "C" windows opened for ventilation. Pushback, engine start and taxy were all uneventful but strong fumes re-appeared (with no visible smoke) on changeover from APU air to engine air. Fumes again only lasted for a couple of minutes with none reported in cabin. Flight uneventful until during descent when smell of fumes returned for approx 30 - 60 seconds each time power reductions were made during stepped descent. Cabin crew member could still smell fumes on flight deck when flight crew could not. Approach and landing normal although fumes returned to flight deck during taxy and remained until engine shut down on stand. Engineers confirmed strong smell of fumes on flight deck. All 3 cabin crew members complained of headaches and 1 had a sore/dry throat. Both flight crew also had headaches/eye irritation and P1 felt dizzy and had difficulty completing Tech Log. Entire crew declared unfit for further flying duties and taken to hospital for blood tests, which were found normal. See also 2000/08340 and other related occurrences contained therein. Investigation progressed under 2000/08340.
A/C Type : BAE146 Occurrence Number : 200008697
Flight Phase : Flight Occurrence Date : 23 Nov 2000
Classification : Occurrences Location : London-Gatwick - LGW
Events : Smoke / Fumes (not engine)
Crew Illness / Incapacitation Location Info :
Pretitle :
Fumes in flight deck and cabin.
Precis :
Prior to departure, both air conditioning packs had been changed and an ADD posted "Do not use APU unless in emergency". At 3000ft, as engine air 1 and 2 and pack 1 were selected 'ON', there was a strong smell of fumes in the flight deck for approximately 60 seconds. Five minutes later, fumes were reported in the cabin for a short duration but not long enough to carry out an isolation procedure. The remainder of the flight was uneventful. On the return flight, there was again a strong smell of fumes on the flight deck for approximately 60 seconds when the pack was selected 'ON' at 3000ft. During the later stage of the cruise, P1 found great difficulty in concentrating, had a dry throat, irritation of the eyes and a headache. The same symptoms were also reported by cabin crew. P2 said he smelt the fumes after take-off but was OK. P1 elected to don oxygen mask, but P2 declined. The remainder of the flight was uneventful. The entire crew were sent to hospital for blood tests, but no symptoms or problems were found. Discussion between P1 and nr1cabin crew, revealed that on both sectors the cabin crew thought that an unusually high proportion of the passengers (40-50% on the first sector, 50-60% on the second sector) were asleep, but there were no complaints of fumes or smells. The aircraft has been withdrawn from service and ferried to the operator's main maintenance base. See also 2000/08340 and other related occurrences contained therein.
CAA Closure: Investigation to be progressed under 2000/08340.
A/C Type : BAE146 Occurrence Number : 200104931
Flight Phase : Flight Occurrence Date : 07 Jul 2001
Classification : Occurrences Location : En Route
Events : Smoke / Fumes (not engine)
A/c Equipment / System Malfunction
Crew Illness / Incapacitation
A/c Maintenance Location Info :
Pretitle :
Smell from air conditioning on numerous sectors. P1 felt effects of fumes. Air conditioning system contaminated when engine oil levels overfilled.
Precis :
During second sector, P1 felt increasingly unwell with headache and with difficulty concentrating. After end of duty time, P1 was quite unwell and slept for over 12 hours (which was unusual). Symptoms returned during 4 sectors flown in the same a/c next day. Preliminary discussion with engineers revealed that engine oil levels had been overfilled at an outstation and air conditioning packs had become contaminated. Reporter comments that this is not the first time P1 has suffered ill effects after flying. Engine oils drained of 1ltr of oil each. No contamination of pneumatic ducts or packs noted. Investigation being processed under 200008340.
CAA Closure: The hazard is adequately controlled by the reporter's actions.
Date A/C Type Location Occ Num
12.11.1999 BAE146 199907922
Flt Phase Location Info
DESCENT
Occ Classification Event(s)
Occurrences Other Occurrence
Pretitle :
Flight crew partial incapacitation - recurred. Possibly due to fumes on flight deck.
Precis :
At FL150 during descent, P2 suddenly felt unwell for approx 10 seconds - P1 then felt sick later. Oxygen masks used by flight crew but P1 continued to feel sick (dizzy groggy). P2, feeling better, assumed control. P1 slowly recovered after approx 2 minutes. Normal approach & landing completed. On previous flights, both flight crew & cabin crew felt unwell with unusual smell/odour evident. Subject to Swedish NTSB investigation. AAIB, a/c manufacturer & engine manufacturer advised. See also 2000/08340 and other related occurrences contained therein.
A/C Type : B757 Occurrence Number : 200308287
Flight Phase : Descent Occurrence Date : 27 Nov 2003
Classification : Occurrences Location : London-Heathrow - LHR
Events : Smoke / Fumes (not engine)
Crew Illness / Incapacitation Location Info :
Pretitle :
Transitory fumes on flight deck.
Precis :
Following RH engine start, with both packs selected off, slight fumes were detected on the flight deck which soon cleared. During the descent both flight crew went on to oxygen, as P1 felt light headed and P2 had a tingling sensation in fingers and lower arm. Fumes removal checklist actioned as a precaution, P1 felt clearer and came off oxygen and a normal descent and approach was carried out. Investigation being progressed under 200308277 (same aircraft one day earlier).
A/C Type : B757 Occurrence Number : 200008363
Flight Phase : Cruise Occurrence Date : 07 Nov 2000
Classification : Serious Incidents Location :
Events : Smoke / Fumes (not engine)
Crew Illness / Incapacitation
Engine Malfunction Location Info :
Pretitle :
Serious Incident : Oily metallic smell evident on flight deck. Flight crew partially incapacitated, numerous ATC calls missed. AAIB Field investigation.
Precis :
Oily metallic smell had also been evident during previous sector. On this occasion, numerous ATC calls were missed, prompting ATC to ask a/c if everything was all right. P1 then forgot to slow a/c during approach until reminded to do so at 3.7d. Crew unaware that they were becoming partially incapacitated. Recurred 11.11.2000, strong smell on flight deck after engine start and throughout the flight. As P1 developed significant headache in and after the flight and an inability to concentrate, he withdrew from the remaining duty. Following this and other reported events, the engine overhauler has worked with the engine manufacturer to develop and improved engine build standard. The operator in turn has also re-inforced the CAA FODCOM message to flight crew regarding the use of oxygen masks, developed improved troubleshooting and corrective actions (engine/APU inspections) following the reported events. However, because of the specific controlling actions taken by the operator and the CAA, there has to-date ( 4.2.2002) only been two further reports (200200461 and 200200807) which are currently (15.2.2002) under investigation, describing the known circumstances. Work also continues to gain an understanding of the reasons for the reported flight crew symptoms.
A/C Type : B757 Occurrence Number : 200007913
Flight Phase : Climb Occurrence Date : 25 Oct 2000
Classification : Occurrences Location : Admis
Events : Engine Fire / Overheat / Smoke
Crew Illness / Incapacitation
Diversion /Return
Engine Malfunction Location Info :
Pretitle :
Fumes on flight deck and in cabin. Recurring fault considered to be residual engine oil contamination in the bleed ducts following an earlier LH engine malfunction. Engine changed.
Precis :
After take-off thrust was set, a strong smell likened to "burning rotten socks" was apparent on flight deck. During climb, smell was still evident on flight deck but not as intense and was also reported from pax cabin where it was strongest forward. Aircraft levelled at FL330 and each pilot in turn breathed 100% oxygen for 1 minute because they both felt light headed. Aircraft diverted to Luton and on shut down, both pilots still felt light headed and also shaky. Reporter confirms that similar incident had been reported on previous sector and that the aircraft has a history of oil leaks from the LH engine during service in Scandinavia although there were no written reports as such. It was confirmed that the oil was entering the flight deck and passenger cabin whenever the left hand engine was supplying conditioned air. The left hand engine was removed and according to the engine manufacturer's subsequent report the LP location bearing had a very deep groove caused by the metal sealing ring lapping against the outside diameter. The front annular panel had evidence of fretting on the 46 bolt flange where the bolts had relaxed their torque causing the spacers to move. Relaxation of these bolts caused an oil leak which was possibly where the fumes on the flight deck had come from. The oily smell was therefore considered to be residual oil contamination in the bleed ducts. There have been no further reports of an oily smell on subsequent flights. See also 200/08363 and other related occurrences contained therein.
CAA Closure: Appropriate action taken operator and engine manufacturer.
A/C Type : B757 Occurrence Number : 200106302
Flight Phase : Climb Occurrence Date : 04 Sep 2001
Classification : Occurrences Location : London-Heathrow - LHR
Events : Smoke / Fumes (not engine)
Crew Illness / Incapacitation
Engine Malfunction Location Info :
Pretitle :
Metallic chemical taste and smell in flight deck atmosphere. Flight crew felt ill effects in flight but were incapacitated on ground.
Precis :
P1 first noted metallic taste/smell during climb but when it became stronger it was cleared by switching off LH air conditioning pack. P2 also aware of smell which returned during descent with both air conditioning packs on. P1 felt slightly "euphoric", "light-headed" and "uncoordinated" on final approach and taxi in - slight errors of judgement and garbled speech also occurred during taxi in. Both P1 and P2 felt unwell during turnaround and did not operate return sector. Cabin crew members had no ill effects during flight but following visit to flight deck after landing, 2 members of cabin crew complained of similar symptoms to flight crew (although unaware of flight crew ailments at the time). Entire crew received medical attention and were advised against flying for 24 hours. During subsequent ground inspection, both engines were run for 5 minutes with RH air conditioning pack on and no fumes/smell evident. ADD raised and a/c released to service with LH air conditioning pack inoperative iaw MEL/DDM. No smell evident during return sector. LH and RH engine spinner/anti ice tubes removed, cleaned and refitted iaw Rolls-Royce Troubleshooting Procedure and FIM 71-05-00. Oil found on both nr1 and nr2 engine spinners. Spinners dried out and no fault found on subsequent ground runs. ADD cleared and a/c returned to service.
CAA Closure: Investigation progressed under 2000/08363.
A/C Type : B757 Occurrence Number : 200201421
Flight Phase : Cruise Occurrence Date : 02 Mar 2002
Classification : Occurrences Location : En Route
Events : Smoke / Fumes (not engine)
A/c Equipment / System Malfunction
Crew Illness / Incapacitation Location Info :
Pretitle :
Both flight crew felt short of breath and light headed during cruise. Fumes suspected.
Precis :
During consecutive sectors, flight crew both felt a gradual deterioration in their condition, light headed with a shortness of breath together with coughing and were unable to breathe normally. Cabin crew were briefed and both flight crew completed flight using 100% oxygen. Fumes on flight deck suspected. Flight crew later reported that there was no oil smell. Air conditioning packs were operated both hot and cold with no evidence of oil smell or fumes. Oil levels and intakes were checked and nothing abnormal found.
CAA Closure: Investigation under 200303506.
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