The object of this paper is to collate and review available data from various sources on
the number of fume related
incidents/reports in aircraft. Only a small selection of data is available for
review and does not take into account
under-reporting of incidents.
|
Year |
Maintenance/aircraft tech log Fume reports/no of BAe146
flights (Mandatory under Civil
Aviation regulations) -Completed by pilot |
No of BAe 146 flights |
No of reports-Mandatory |
source |
|||
|
1992 |
1 per 66
flights |
27778 |
418 |
Ansett Senate evidence (Hansard) 2/11/99 Final report 2.54
and Ansett update #8 30/7/98 |
|||
|
1997 |
1 per 128 flights |
|
189 |
||||
|
1999 to June30 |
1 per 131
flights |
22004 |
168 |
Ansett FA Information Kit May 2000-supp Senate volume and
Final report 2.50 |
|||
|
|
|||||||
|
“ the source
of the odours has been identified as predominantly Mobil Jet Oil 2 leaking
past oil seals in the engines and /or Auxiliary Power Unit into the air
conditioning system” 13 BAe 146 aircraft in Ansett fleet as at 9/1999 |
Ansett
Senate evidence 2/11/99 p54 Ansett evidence to Senate, Volume 2, Sept 99 |
||||||
|
Aircraft
maintenance technical log completed by pilot – mandatory as per Civil
Aviation Regulations (CAR’s) National Jet Systems
/ Qantas BAe
146 fume/odour occurrences
|
|||||||
|
1999 |
Cabin air quality crew report-1 per 785 flights – over
1/fortnight- “not all but most of the fleet have experienced some sort of a
report It is not one aircraft” |
Qantas Hansard 1/2/00 pp 125-126 |
|||||
|
1999 |
“As there are nearly 30,000 flights per year there is some
sort of contamination reported … at 0.1%” “Our incidence of oil leaks has been… Around 0.1% of flights departed … It is maybe around 1 per fortnight” |
NJS Hansard 1/2/00 pp 135-138 |
|||||
|
4/01-9/02 |
NJS
defect reports to CASA 4/01-9/02 – 51
defect reports- |
Aust
parliament Hansard- 2/12/02 |
|||||
|
1/00-8/02 |
16 ASIR ATSB reports- NJS
|
ATSB, Senate Hansard, 19 Aug 02 |
|||||
|
Nov/Dec 2002 2002 |
Significant
Increase in reports
In the calendar year, 2002, National Jet Systems removed 141 BAE146 engines from its aircraft fleet. The vast majority of those removals being related to cabin air quality issues. It is pertinent to note that this experience is unique to Australia. On International figures from other BAE146 fleets would expect to remove the maximum of 36 engines in a year having regard to the size of the National Jet System fleet |
AUSTRALIAN INDUSTRIAL RELATIONS COMMISSION U2002/6475 NEVAN PHILLIP PAVLINOVICH and NATIONAL JET SYSTEMS PTY LIMITED-18/3/03 |
|||||
British Aerospace –BAe 146
British Aerospace- Swedish BAe 146 Incident report- RL 2001:41e (www.havkom.se)
|
Period |
No of reports passed to BAe |
No of reports involving impairment of crew capacity |
Reports judged as serious due negative
effect on flight safety-(CAA-MOR) |
Description |
|
6/92-1/01 |
|
22 (flight crew) |
7 |
|
|
1/96 – 9/99 |
212-1 airline operator |
19 (7 submitted directly by crew) |
|
Tainted cabin air |
|
5/85- 12/00 |
227-36 (other) operators |
11 |
|
Contaminated cabin air |
|
“Reports of cabin
air odours have been received from time to time and have predominantly been
determined to be due to minor systems failures such as leaks from oil seals
on the aircraft engines or APU” “every engine leaks oil from it’s
seals and bearings … as recently as 1996-97 we continued to improve the
sealing properties of the bearings and the seals” "we all acknowledge .... that the modifications will not solve the
problem completely They are to reduce
the number of events and that is what is important". "the modifications are really
around the reliability of the seals and making sure that they do not fail as
frequently So they are improvements
to reliability, rather than improving the quality of the sealing." "The air supply is protected
from contamination by seals, which achieve maximum efficiency during steady
state operation However, they may be
less efficient during transients (engine acceleration or deceleration) or
whilst engine is still achieving an optimum operating temperature Improvements in seal design continue to
increase efficiency, and when available, modifications are provided for the
engines and APU.” |
BAe- evidence to Australian Senate Vol 1, sub11 3/9/99 BAe Senate Hansard 2/11/99 p 85 BAe Senate Hansard 10/4/00 p 236 p229 BAe Manufacturer’s Operations
manual-Notice to Aircrew and BAe All Operator Message-Ref 00/030V, Jan 01 |
CASA-Civil
Aviation Safety Authority of Australia
NJS
defect reports to CASA 4/01-9/02 – 51 reports-Aust parliament Hansard- 2/12/02
http://www.casa.gov.au/avreg/aircraft/sdr/turbine.htm
22+ reports of
fumes / seal bearing defects /oil contamination –ALF 502R5 and ALF 507 engines
|
year |
reports |
|
2001 |
8 |
|
2000 |
5 |
|
1999 |
3 |
|
1997 |
4 |
|
1996 |
2 |
CAA-Civil
Aviation Authority- UK
|
Years |
Fume reports |
Notes |
Source |
|
1989-1999 |
1: 22,265
flights 128 incidents
in 2,850,000 flights |
Total smoke or gas fume reports - 5 aircraft types on UK
register ·
17-BAe 146 20- A320 ·
21- B757 33- B737 |
CAA, 1999 |
|
1996 1999 2000 (to
Nov) |
81 156 124 |
Smoke, odours, fumes “the number of reported incidents per annum of smoke,
odours, fumes etc entering UK
aircraft flight decks or passenger cabins over the past 5 years or so has
increased from 81 in 1996 to 156 in
1999, and 124 to date in the year 2000
The letter was written on 30 November and there may have been
further incidents subsequently” |
DETR correspondence. M Meacher MP to P Tyler MP 30/11/00,
House of Commons Hansard, 16/1/01 |
|
1985-2002 |
64 |
BAe
146-MOR’s (Mandatory Occurrence Reports) “ smoke and or fumes” – oil / smoke / fumes and other
contamination incl de-ice/hyd fluid §
1985-1995
-11 §
1996-2001
-52 |
MOR reports - CAA Mandatory Occurrence reports Including 1999-2001: 21 cases involving crew illness/
incapacitation-impairment of which 4 involved 2 flight crew |
|
1992-2002 |
56 |
B 757-MOR’s “ smoke and or fumes” – oil / smoke / fumes and other
contamination ·
1992-1998
-12 ·
1999-2001
–33 ·
9/01-12/02
-11 |
Including in 2001: 18 cases involving ‘crew illness/
incapacitation’ of which 11 involved 2 flight crew |
FAA
–Federal Aviation Administration -USA
167 incidents in 10 years to
2001 - BBC file on 4, Dec 01
Air Safety Bureau Incidents – oil fumes/air conditioning and associated- (BAe 146 except where marked)
|
Bureau |
Date |
No of
incidents and aircraft type |
Source |
|
ATSB Australia |
1991-1999 |
10 – BAe 146 – 12 - 7 Jet aircraft types (excluding BAe 146) http://www.basi.gov.au/occurs/ob199702276.htm
-NJF,7/97 Brisbane Incident- 1997 Hamilton Island Incident- 29/10/97 |
ATSB- summary of fume/smoke /odour related occurrences ** ATSB Senate report |
|
ATSB ATSB |
11/99-5/01 1/ 00- 8/02 |
8 –BAe 146 - 5 – B737 and 767 http://www.basi.gov.au/occurs/ob200002431.htm
-NJL,30/4/00 Occ- 200001175, - JJZ 31/3/00 Occ- Occurrence 200001331 - JJP 13/4/00 16 reports- NJS- ATSB http://www.atsb.gov.au/aviation/occurs/occurs_detail.cfm?ID=400 NJA, 7/8/01
http://www.atsb.gov.au/aviation/occurs/occurs_detail.cfm?ID=399 JJU 18/7/01
http://www.atsb.gov.au/aviation/occurs/occurs_detail.cfm?ID=398
NJR 31/5/01 http://www.atsb.gov.au/aviation/occurs/occurs_detail.cfm?ID=427
NJY, 24 May2001
|
Aust Senate Hansard-RRAT, 31/5/01 ATSB Senate evidence and Hansard 1/5/00 Aust Senate Hansard- Aug19,2002 ATSB |
|
Board of Accident Investigation-Sweden |
12/11/99 |
1- BA 146 - RL 2001:41e |
Statens Haverikommission |
|
AAIU Ireland |
24/11/97 |
1- BAe 146 |
AAIU |
|
AAIB |
14/3/00 5/11/00 7/11/00 8/2/01 19/5/01 10/11/02 |
2- BAe 146 §
http://www.aaib.detr.gov.uk/bulletin/aug01/oodjs.htm §
see -MOR
Occ-200008340 –not released 4-B757 §
MOR200008363 MOR200100784 MOR200103267 MOR200208123 |
AAIB CAA BAe 146 MOR report (see AAIB recommendations in above
Swedish BAe 146 report- p26) CAA B757 MOR report |
** ATSB summary of fume/smoke/odour related occurrences 1991-1999 include oil fumes/ galley / hydraulic, electrical fumes , other and no source found- 148 incidents- (reported as 93 Aust Senate Inq hansard, 1/11/99. However events listed in table above refer to oil fumes. Air conditioning & related incidents.
BAe 146 odour Ocurrence
Reports -Discretional
|
Airline |
Date |
No of reports |
Source |
|
Ansett |
12/91-5/92 |
378 (6/7 aircraft) |
Flight Attendant Association of Aust (FAAA) Senate
evidence |
|
Ansett |
8/92- 8/99 |
312 |
|
|
Ansett |
9/99-8/00 |
82 |
|
|
NJS |
5/99-7/00 |
19 |
|
Total |
1991-2000 |
791– discretional
(not included in aircraft mandatory
tech log reports-above) |
·
“Ansett
estimates the reporting rate of fumes occurrences conservatively at 50%” - FAAA
submission 24 - Senate evidence
·
“… strong
evidence of a tendency of pilots to under-report incidents” - 6.18 -
Senate final report-
§
see ATSB occurrence report OB 200002431 –above as example of
under-reporting http://www.basi.gov.au/occurs/ob200002431.htm
§
refer various MOR reports for evidence of under-reporting
e.g.
o
BAe 146 200104931- Crew illness incapacitation / Not 1st
time P1 has suffered ill effects after flying
o
200101217- smoke/ fumes in cabin- ‘no tech log entry made’
o
200006659 -reporter comments that smoke formation is a known
occurrence on this aircraft
o
200104071 – defect persisted over several months
o
B-757-200008363 7/11/00 –Serious Incident/Partial
incapacitation- Recurred 11/11/00- nil
MOR
o
200100984 –
recurring fault – nil MOR’s
·
BAe 146 Pilot
and Flight Attendant Public Submissions to Australian senate Inquiry
o
Pilots-6 -2 report
loss of pilot medical certificate- others known
o
Flight Attendants-5
o
“20 individual
submissions received describing symptoms experienced by crew and attributed to
oil fumes leaking into the aircraft cabin”
·
US ASRS
–(Aviation Safety Reporting system) (C
Van Netten- Hydraulic fluids and Jet oil, 2001) – see other reporting
formats Voluntary 1988-1998 - Air quality self reported incidents – 63 reports
|
o
engine oil seal failure 4 o
APU oil seal failure 14 o
APU hydraulic fluid contamination 7 o
Air conditioning pack failure 8 o
Air Con filter contamination 1 o
Duct contamination 4 o
Undetermined oil odours 4 o
Undetermined smoke and smell 6 Total 48 |
·
C Van Netten : Air quality and Health effects Associated
with the Operation of the BAe 146 Aircraft., 1998
o
112 out of 200 flight crew report 172 symptoms on 5 aircraft
of 35 flights each
·
AFAP-Australian Federation of Air Pilots-1999 BAe 146
crew health Survey
o
21 BAe 146 crew (19 Pilots) –report variety of health
symptoms and work on BAe 146 –short & longer term effects
o
95% report symptoms increased since flying BAe 146 *
o
63% report symptoms do not increase same amount on other
aircraft *
o
84% report symptoms increase more on duty *
o
68% report symptoms increase more on BAe 146 than elsewhere
*
*some failed to answer
o
Comments incl.:
§
“On flights of 4 hours +, extreme headaches usually occur
the next day and last for 24 hours” ,
“violent protracted headaches”
§
”Eyes become bloodshot and painfull”
§
“Fatigue and lack of attention to detail has been evident
for quite some time”
§
“nausea felt whenever odour present”
·
BALPA-British
Airline Pilots Association- Crew health survey-2001
o
106 responses out of 600 surveys sent out – smoke/fume
events
§ 96 responded
they had experienced smoke or fumes on
the flight deck
o
93 B757 pilots report 1667+ fume/smoke events on flight deck. 80 pilots thought
these related to oil contamination of air system (many reported several events
which are counted here as only 2)
o
Only 61 confirmed ASR reports out of 1667+ B757 fume events. (Others
reported by internal Company reporting -(not available for review)
o
1 reported several events on BAe 146-oil fumes =2
o
89 report both pilots experience fumes
o
Oxygen generally not used with belief that short exposures without visible fumes not worthy
of using O2
o
Symptoms reported range from short to longer term
o
Comments incl.:
§
“Captain had degraded attention & I could not allow him
to fly the approach or landing”
§
“I feel that as a regular reporter of fumes in the flight
deck that engineering are not taking my reports seriously…”
§
“After my most noticeable occurrence, I experienced tingling
in the extremities for 24 hours..lower than normal concentration/memory”
§
“Every 3rd or 4th sector on the B757 I
can detect oil vapor”
·
AFA-Association of Flight Attendants
760+
incidents over a nine year period to 1997 at one airline (7/month.) – primarily MD80- Now 1000+
·
CUPE- Canadian Union of Public Employees
o
1993-1997 survey- 462 reports of flights with
symptoms associated to air quality.
o
1992 Survey-292 cabin crew responded to survey (July-
Dec92)- mainly A310/20
§
33% reported health problems 1 or 2 times
§
37% reported health problems 3 or more times
·
A. Chew V East west
& Ansett –Compensation court of NSW- Oct 93 Hobart incident BAe 146
·
7 case studies : illness & LT effects/actions incl:
2 BAe 146 flight crew with suspended / loss of flying licence
& 2 BAe 146 cabin crew , 1 each cabin crew off B747/ F100/B727- " Aircrew exposure to chemicals in aircraft: Symptoms
of irritation and toxicity" C. Winder & J.C Balouet , 2001
·
R Rayman- Smoke/Fumes
in the cockpit –1983 184 symptoms
reported in
89 USAF incidents of smoke/fumes
in the cockpit, (Dir Aerospace Med
Assoc)- 1970-1980
|
Origin: Substance o Unknown 36 o Oil 23 o Fuel 7 o Hydraulic
fluid 4 o CO 3 o 17 other
sources 28 |
Note:
Compiled
by air crew, March 2003