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Oil and hydraulic fluid contamination of aircraft air supplies. An overview of the health and flight safety implications

Oil and hydraulic fluid contamination of aircraft air supplies. An overview of the health and flight safety implications. December 2007. Susan Michaelis. Former Captain and BAe 146 pilot. Head of Research at the Global Cabin Air Quality Executive (GCAQE).

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Oil and hydraulic fluid contamination of aircraft air supplies. An overview of the health and flight safety implications

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  1. Oil and hydraulic fluid contamination of aircraft air supplies.An overview of the health and flight safety implications.December 2007

  2. Susan Michaelis • Former Captain and BAe 146 pilot. • Head of Research at the Global Cabin Air Quality Executive (GCAQE). • Working towards a PhD on the contaminated air issue at the University of New South Wales in Sydney. • Author of the Aviation Contaminated Air Reference Manual (2007). (ACARM) • Data in presentation – Refer ACARM

  3. GCAQEThe Global Cabin Air Quality Executive (GCAQE) is the leading organization globally representing air crew with regard to cabin air quality, specifically contaminated air issues and representing over 400,000 aviation workers globally in 3 continents.www.gcaqe.org

  4. Aviation Contaminated Air Reference Manual (ACARM) • Published in 2007. • 1st time data has been collated. • 844 pages of data collected globally from 1997 - 2007. • Aviation industry data from 1953 - 2007 (54 years). • Data is fully referenced. • Data taken from a wide variety of sources • Data confirms there is a problem.

  5. Industry documents -wide variety Published papers Surveys Union reports Defect reports Regulator reports Medical reports Legal / insurance reports Government data Scientists & doctors Aircrew & passengers Media Bureaus of air safety Industry meetings & conferences ACARM data taken from:

  6. What is the problem? • ‘Bleed Air’ contaminated with pyrolised / heated engine oils and hydraulic fluids. • ‘Bleed Air’ is not filtered. • No contaminated air detection systems on aircraft. • Ground based safe levels cannot be applied • Flight safety is being compromised. • Passengers and crews suffering short and long term health effects. • Under reporting of events is significant. • Industry failing to tackle the problem.

  7. Contaminated air is predominantly related to oil fumes • Rolls Royce 1990:‘The approach adopted some years ago by Rolls Royce was to recognize the fact that in the majority of instances where cabin air contamination was a problem, it was mostly associated with small leakages of synthetic lubricant from bearing seals etc.’ • ATSB:‘Failure of oil seals has been a common factor in the majority of cabin fume incidents.’ • CASA:‘All aircraft from time to time suffer fumes within the aircraft… that is a feature of the basic design of air-conditioning systems in aircraft, being bleed air from engines.’ • CAA, Ansett, BAe…‘Oil leakage is primary cause of fumes.’

  8. How long have we known about these problems ? • There is a very extensive database of information showing how long this issue has been known. (ACARM 2007) • 1953: Aero Medical Association Committee of Aviation Toxicology –Toxicity of Oils & Hydraulic fluids • 1977: Incapacitation of Air National Guard C-130 Hercules navigator due to inhalation exposure to aerosolized or vaporized synthetic lubricating oil. • Extremely large body of evidence showing this is known about & a problem

  9. What is in contaminated air? • Data from an actual contaminated air event never published in peer reviewed paper. (NRC, HOL, UK Gov) • Over 200 chemicals identified in various tests after events, during normal conditions, pack burns etc... • Most synthetic jet engine oils contain: • Organophosphate, TCP (antiwear additive) at 3% - (ortho isomers >0.3% [Mobil 2000] - hazardous / toxic levels • PAN, skin sensitizer (antioxidant) - 1% - Hazardous levels • BNA – Cat 1 known & prohibited human bladder carcinogen • Synergistic mixture of substances • Unknown / proprietary substances • Inhalation toxicity testing for exposure to heated jet engine oils has never been done. • ‘NYCO’ oils do not contain TCP – e.g. Tubonycoil 600

  10. Identifying contaminated air exposure Contaminated air descriptions include: • Oily Sweaty-sock-like • Locker room Aromatic (like benzene) • Wet dog Acrid • Hot oil Burnt oil • Pungent Dirty Socks Descriptions will vary

  11. Flight Safety is being compromised • Same pattern occuring globally • 1050 UK CA events in the ACARM database showing: (2005 examined) – (ACARM 2007) • Number of events increasing over the years. • Events occur on many aircraft types. • Based upon 2005 figures: up to 750,000 people potentially exposed without even taking into account under-reporting. • Only 48% of contaminated air events reported to CAA • 32% of reported CA events involved some degree of crew adverse impairment. • 20% of CA events involve at least 1 pilot impairment. • 9% of CA events involved 2 pilot impairment.

  12. Flight Safety is being compromised • Adverse effects / impairment ranges from minor effects through to incapacitation. • Oxygen used by 1 pilot only 4% of the time and both pilots 12% of the time & usually temporarily only. • Many events seen as not reportable (not reported in tech log) or occur over numerous sectors. • Engineering is often not finding source of the problem on first inspection. • Crew errors being made. • Crews continue flight duty after exposure events. • Fume events often seen as normal or a nuisance only. REGULATIONS NOT WORKING

  13. Helios & Malmo • Helios • Oil fumes reported prior to crash –please report further/ intermittent • Crews reported smoke, fumes & symptoms prior to crash • Malmo • Crew incapacitated • Oil leakage found • Synergistic effects despite all levels reported as safe

  14. SHORT TERM LONG TERM Crews are losing medicals/ careers Medical effectsCrew And Passenger ‘Aerotoxic Effects’ Following Inhalation Of The Heated Products Of Synthetic Jet Engine Oils And Hydraulic Fluids Can Be:

  15. Major concerns • Smoke and fumes are not rare: • ATSB 1999: ‘smoke and fume contamination of cabin air is neither a new phenomenon nor a particularly rare event and that over time, it has been experienced in many aircraft types.’ • Air National Guard paper 1977, Rayman (AsMA), 1983, Ansett 2000, RAAF 2004, AAIB 2004…. • Fumes have been seen as a non event/nuisance- BAe 2001, Canadian TSB 2000 • Serious under-reporting is occuring: APH 2000, BALPA 2003, Norwegian CAA, FAA 2006, ACARM 2007

  16. Is contaminated air a flight safety or an OH&S issue? • “Oil fumes are more of a health problem than an aircraft technical defect.” CASA2003 • “Toxins in the cabin air are more of an OH&S issue and not the responsibility of the aviation regulator.” CASA 1999 • “Outside regulator’s, manufacturer’s & airlines expertise.” BAe (2000), CASA 2000 • Worksafe: Responsibility of CASA BOTH- Australian Senate, aviation & OH&S regulations….. and common sense!

  17. Airworthiness Ventilation Regulation: 25.831 • (a) …. the ventilation system must be designed to provide a sufficient amount of uncontaminated air to enable the crewmembers to perform their duties without undue discomfort or fatigue and to provide reasonable passenger comfort. (b) Crew and passenger compartment air must be free from harmful or hazardous concentrations of gases or vapors.

  18. Regulations are not being met • Most events are not being reported • Most events are not being passed on to the regulators • Smoke/toxic/noxious fumes are in all cases reportable – major defect, MOR…

  19. The system is not working • Regulators & aviation industry fail to recognize system is not working and deny: • Under-reporting is occuring. • Many events as ‘lesser events’ or not ‘safety related’. • Regulator & industry data is flawed. • DHL advises crews low level fumes after start, taxi, take off…. do not need to be reported as normal. This is seen as acceptable by the CAA (HOC 127960, March 2007) • Regulations not being adhered to or enforced

  20. What is the aviation industry view? 1/2 • Large body of ‘anecdotal evidence, however rigorous epidemiological studies not yet undertaken & more definitive studies required to investigate and evaluate the problem: (ignoring all other data) • All studies under normal operations show cabin air as suitable (irrelevant) • TCP not found or insignificant : (wrong) • Most studies are not looking at contaminated air events and not using techniques required to find contaminants of concern such as TCP.

  21. What is the aviation industry view? 2/2 • Looks towards ASHRAE standard, COT, ACER & OCHRA, ICE– Many are irrelevant or seriously flawed such as UK Committee of Toxicity • Most data available showing the extent of the problem is simply being ignored.

  22. Solutions • DO EXIST • It’s time to implement them • We can fix this problem together

  23. Thank you for your attention.Aviation Contaminated Air Reference Manual -ISBN9780955567209 susan@susanmichaelis.comwww.susanmichaelis.com

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