Air Safety Recommendations
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COUNTRY
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Air Safety Recommendations
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COUNTRY
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1. Australian Transport Safety
Bureau – 6 September, 1999
-Occurrence Brief 199702276 - Incident 10 July, 1997
http://www.basi.gov.au/occurs/ob199702276.htm
The Bureau of Air Safety Investigation is particularly concerned about the potential for further BAe146 flight and cabin crew to become incapacitated during flight due to exposure to odours being introduced into the aircraft cabin environment. In this occurrence, two of the three flight crew members on board the aircraft suffered from symptoms that prevented them from properly carrying out their assigned duties. The introduction of fumes and odours into the cabin environment following an engine defect constitutes a possible safety deficiency that should be addressed by the regulatory authority, in accordance with its statutory responsibility to monitor the continued airworthiness of aircraft.
The implications of long-term exposure to cabin air contamination for the health of passengers and crew requires further examination, together with the development and implementation of suitable counter-measures. The competent authority to co-ordinate such activities is the regulatory authority.
The Bureau of Air Safety Investigation recommends that:
R990052
The Civil Aviation Safety Authority, in conjunction with the aircraft manufacturer, British Aerospace Plc, address deficiencies that permit the entry of fumes into the cockpit and cabin areas of BAe146 aircraft. These deficiencies should be examined by the regulatory authority as part of its responsibilities for initial certification and continued airworthiness of the BAe 146 aircraft.
R990053
British Aerospace Plc liaise with the engine manufacturer
AlliedSignal to investigate failures within the engine that result in fumes
entering the cockpit and cabin areas of BAe146 aircraft.
2. Australian Transport Safety Bureau- 4 July, 2001
Occurrence 200102467 -BAe 146 , 31/5/01
http://www.atsb.gov.au/aviation/occurs/occurs_detail.cfm?ID=398
Occurrence 200103238 –BAe 146 , 18/7/01
http://www.atsb.gov.au/aviation/occurs/occurs_detail.cfm?ID=399
Occurrence 200103696 –BAe 146, 7/8/01
http://www.atsb.gov.au/aviation/occurs/occurs_detail.cfm?ID=400
SAFETY ACTION
On 6 September 1999, the Australian Transport safety Bureau issued recommendation R19990052 to the Civil Aviation Safety Authority. That recommendation stated that:
"The Civil Aviation Safety Authority, in conjunction with the aircraft manufacturer, British Aerospace Plc, address deficiencies that permit the entry of fumes into the cockpit and cabin areas of BAe 146 aircraft. These deficiencies should be examined by the regulatory authority as part of its responsibilities for initial certification and continued airworthiness of the BAe 146 aircraft."
The Civil Aviation Safety Authority responded on 14 March 2000 stating:
"In the lengthy period between the incident and the release of your report, CASA has investigated this issue in considerable detail, in conjunction with the aircraft manufacturer and the major Australian operators. As a result of this work, and discussions with the certifying authority (the UK Civil Aviation Authority), CASA is satisfied that the BAel46 aircraft in service in Australia are safe for public transport. CASA technical specialists are available to brief your investigators on the scope and findings of this work.
"As your recommendation does not specify the nature of any additional deficiencies that the Bureau believes need to be addressed by CASA and the aircraft manufacturers, I am seeking details of any deficiencies that you believe have not been appropriately dealt with. It would also assist us in providing a meaningful and constructive response to your recommendations if you were to provide us with details of any incidents that have occurred since the original incident in 1997.
"In the meantime, we will continue to monitor the situation and review any information that comes to hand."
The Bureau classified the response as "Open" and has initiated further correspondence with CASA. On 12 October 2000, the Senate Rural and Regional Affairs and Transport References Committee tabled its report into Safety and Cabin Air Quality in the BAe 146 Aircraft. The Government tabled its response to the References Committee's report on 28 June 2002.
SWEDEN
RECOMMENDATIONS
The Swedish Civil
Aviation Administration is recommended to work in consultation with the foreign
civil aviation authorities concerned to encourage:
– that existing
emergency checklists and emergency training programs are complemented regarding
immediate steps to be taken when suspicion arises that the cabin air is
polluted. The instruction for such occasions shall
call for the immediate use of the oxygen mask selected to 100 %
– that a plan of
action is developed for how crews and aircraft shall be handled directly after
landing if an incident with polluted cabin air has occurred
– that an
international database is established with factual information from flights
where suspicion of polluted cabin air exists
– that research
efforts are initiated in regards to the characteristics of modern lubricating
oils under very high pressure and temperature and their influence on the health
of human beings
UK
Because of this and
several similar incidents which affected aircraft types other than the BAe 146,
the AAIB on 4 May 2001 made five recommendations (Ref: EW/C2000/11/04) as
summarized below:
It is recommended
that the CAA in conjunction with BAe develop the required maintenance and
modification standards for the aircraft type BAe 146 which shall ensure that
oil by-products cannot accumulate in the air-conditioning system and pollute
the cabin air.
It is recommended
that the FAA, in conjunction with Boeing develop the required maintenance and
modification standards for the aircraft type Boeing 757 which shall insure that
oil by-products cannot accumulate in the air-conditioning system and pollute
the cabin air.
It is recommended
that the CAA initiate high priority research efforts with the intention of
determining the substances that can enter the cabin air on the aircraft type
BAe 146, should oil leakage arise from the engines.
It is recommended
that the CAA investigate whether any of the components that are identified
according to recommendation 2001-6 above, can negatively affect the persons
onboard physiologically and/or neurologically. In
the recommendation the Flight Operations Department Communication (FODCM)
17/2000, which was issued by the CAA on 28 December 2000 is referred to. Herein
are described the immediate steps to be taken if any crewmember appears to be
affected by contaminated cabin air during flight.
It is recommended
that the CAA consider issuing additional instructions about how the crew should
react to the suspicion of unhealthful cabin air. The instructions shall call
for the pilots use of oxygen masks selected to 100% oxygen and that the cabin
personnel shall actively and regularly observe the state of health of the
pilots.
USA
