Oil and hydraulic fluid contamination of aircraft air supplies' An overview of the health and flight

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Oil and hydraulic fluid contamination of aircraft
air supplies. An overview of the health and
flight safety implications.10 October 2007-
RAeS
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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

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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.
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(No Transcript)
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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 confirms there is a problem.

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ACARM data taken from

• Government data
• Scientists doctors
• Aircrew passengers
• Media
• Bureaus of air safety
• Industry meetings conferences

• Industry documents -wide variety
• Published papers
• Surveys
• Union reports
• Defect reports
• Regulator reports
• Medical reports
• Legal / insurance reports

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Example of data sources How often do
contaminated air events occur?

• Industry regulator data, statements
• SB, AOM
• Bureaus of Air Safety
• Published papers
• Military
• Government inquiries
• and Hansards

• Crews, passengers
• Defect, engineering reports, MORs, SDRS AIDS,
  internal reports..
• Union reports
• Surveys
• Legal, medical data
• Media

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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.
• 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.

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Contaminated air is predominantly related to oil
fumes

• Rolls Royce1990 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.
• British Aerospace 1999 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.
• Others CAA, CASA, Ansett, ATSB

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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)

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1953 Aero Medical Association Committee of
Aviation Toxicology

• Concerns about toxicity of various aviation
  products including oils hydraulic fluids.
• AMA CAT (1953) Aviation Toxicology an
  Introduction to the Subject and a Handbook of
  Data.

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1977 Air National Guard C-130 Hercules

• This report documents the incapacitation of an
  aircraft navigator during flight. This situation
  resulted from an inhalation exposure to
  aerosolized or vaporized synthetic lubricating
  oil.
• Further investigation into the potential hazards
  from inhalation of synthetic oil fumes is
  definitely warranted.
• Montgomery, M.R., Wier, G.T., Zieve, F.J.,
  Anders, M.W. Human Intoxication Following
  Inhalation Exposure To Synthetic Jet Lubricating
  Oil. Clinical Toxicology 1977 11 423-426.

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What is in contaminated air? 1/2

• Data from an actual contaminated air event has
  never been published. (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 gt0.3 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

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What is in contaminated air? 2/2

• Oil Pyrolysis air studies identify range of
  substances TCP isomers, TPP, Formaldehyde,
  hydrocarbon matrix (Fox).
• Hydraulic fluids contain high levels of the
  organophosphate TBP.
• Inhalation toxicity testing for exposure to
  heated jet engine oils have never been done.
• Nyco oils oils do not contain TCP e.g
  Tubonycoil 600

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A contaminated air event

• Often has NO visible fumes
• Usually has a smell but not always (CO)
• Smell can be faint and need to focus to smell it
• Loss of ability to smell chemicals can occur
  within minutes
• Often seen as the normal aircraft smell
• Sense of smell and description WILL vary
• May be one off event or repeated events.
• No detection systems fitted

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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

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TCP misunderstandings 1/2

• TCP is Tricresyl Phosphate and not TCP from
  Boots!
• TCP for synthetic jet engine oils manufactured
  only in two plants in the world and has a unique
  chemical signature.
• TCP has several isomers which fall into 3
  families ORTHO, META and PARA.
• ORTHO isomer neurotoxicity has been known since
  before the first car!
• META and PARA chronic toxicity now emerging.
• Exposure standards used incorrectly (Mobil 1999).

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TCP misunderstandings 2/2

• ORTHO isomers divided into TOCP, DOCP and MOCP.
• Focus has been on TOCP with UK House of Lords and
  CAA reports of 2000 and 2004 failing to ever
  mention DOCP or MOCP.
• TOCP 0.006 ppm Toxicity factor x 1
• DOCP 6 ppm Toxicity factor x 5
• MOCP 3070 ppm Toxicity factor x 10
• In ignoring DOCP and MOCP you underestimate the
  total ORTHO toxicity by a factor of 6.14 million
  which has been known since 1958!
• Must not refer to TOCP alone (Henschler 1958)

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Exposure standards do not apply to aviation

• Exposure standards are for SINGLE compounds and
  not for the SYNERGISTIC EXPOSURE EFFECTS when
  exposure to contaminated air occurs.
• Acknowledged by AsMA (2002), Honeywell
  (1997/2000), UK Government (2005), RAAF (2004),
  Avmed experts (1988) Occupational Health Doctors,
  Scientists
• Many in airline industry say all levels monitored
  are safe
• Exposure standards cannot be applied
• Synergistic effects of mixture are ignored
• Swedish Malmo oil leak incident 1999 all levels
  determined to be below standards, yet effect was
  incapacitation

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Are crews being exposed ?

• TCP found in crew blood tests and on crew
  clothing.
• TCP found in swab tests from the surface of the
  flight deck cabin walls and in cockpit roof top
  filters, HEPA filters. (2005-2007)
• Australia, UK, USA, Europe
• B747,B777,B767,B757,B737,A330,BAe146,MD80,DCH8
  85 positive
• TCP found in aircraft ducting. (CAA 2004)
• TCP found in air sampling by RAAF (1988, 2005)
  and Honeywell (1997,2000).
• Allied Signal 1997 TCP detected 4 times greater
  than allowed (Australian Senate, 2007)
• CO detected in flight on the BAe 146 in 83 of
  surveyed flights. (ACARM 2007)
• Many other contaminants identified.
• YES
• to a SYNERGISTIC MIXTURE

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TCP blood test (Biomarker)

• GCAQE and other groups such as the RAAF are
  developing a blood test to confirm not only
  exposure to TCP from engine oils but also time of
  exposure.
• Expected in 2008.
• Medical effects of exposure to TCP at levels
  found in crew blood tests also being
  investigated.
• Initial data on health effects, blood test gene
  toxicity regulation will be presented in
  Brussels, December 2007 (Flight International
  Crew Management Conference).
• Dr B Singh RAAF - Avmed / Prof C Furlong UW

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Medical effectsCrew And Passenger Aerotoxic
Effects Following Inhalation Of The Heated
Products Of Synthetic Jet Engine Oils And
Hydraulic Fluids Can Be

• SHORT TERM
• LONG TERM

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Short term IN-FLIGHT effects

• These may include some or all of the effects
  listed
• Nausea, vomiting Headaches
• Disorientation Sore nose, eyes, throat
• Skin Rashes Chest pains
• Tingling or numbness
  Breathing difficulty
• Stupor
  Lethargy
• Tunnel vision
  Difficulty concentrating
• Tremor Short term memory problems
• Vertigo Light headedness etc.

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Long term health effects

• These may include some or all of effects listed
• Neurological effects CNS,PNS Jamal 1997, Jamal,
  Julu 2002, 2005
• Autonomic nervous system effects Jamal, Julu
  2002, 2005
• Working memory / cognitive problems.
  (neuropsychological), Coxon 2002 / Mackenzie Ross
  2006
• Chronic neurotoxicity (OPICN) Abou-Donia 2004
• Respiratory disorders Burdon 2005
• Immune system effects, fatigue, chemical
  sensitivity etc..
• Blood pathology disorders
• Strong occupational link Cone 1983,1999 / Harper
  2005

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What are the overall health concerns?

• Short and long-term health effects are occuring.
• Effects seen are supported by published papers,
  chemical data
• 2007 BAe 146 pilot health survey preliminary
  data (n242)
• 86 acknowledge exposure to contaminated air.
• 57 report short, medium or long-term health
  effects.
• 25 report medium to long-term health effects.
• gt8 early medical retirement or loss of medical.
• Crews being diagnosed / misdiagnosed with MS,
  Parkinsons, CFS, MND, Alzheimer's, depression,
  PTSD, bipolar disorder
• Term Aerotoxic Syndrome to be utilized (APH
  2000).

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Health data taken from

• Medical reports.
• Pilots LOL medical reports - accepted by
  regulators.
• Published papers conferences.
• Health surveys.
• Legal insurance reports.
• Surveys.
• Data shows clear pattern clear links with
  exposure history.
• Health effects accepted by Australian Senate
  2000, 2005 BALPA London Conference, (Various
  Short-term effects by some airlines, NTSB 1983,
  Mobil 1983 ), Regulators for pilot LOL.,
• Data must NOT be ignored, however it is by many

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IS contaminated Air a Flight safety Risk?

• YES

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Contaminated air events seen as normal or a
nuisance 1/2

• fume events may have become routine in the
  thinking of some operating crew and awareness of
  the possible risks may have diminished as a
  result. (ATSB 2002)
• In the past, oil leaks and cabin/flight deck
  odours and fumes may have come to be regarded as
  a nuisance rather than a potential flight safety
  issue. (BAe 2001)

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Contaminated air events seen as normal or a
nuisance 2/2

• Fumes often seen as non event TSB Canada 2000.
• Oil leaks occur as a function of design of air
  supply systems, oil seal design CASA 1999, BAe
  2000.
• Oil leaks at standard industry level BAe 2000.
• Crews are not always fully alert to the
  possibility of air contamination regarded fume
  events as a nuisance rather than a hazard AAIB
  2004.
• FLIGHT SAFETY IS BEING COMPROMISED

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Is contaminated air rare?

• FAA Contaminated air events/smoke/fumes occur
• 2002 once per 3.59million departures.
• 2005 smoke or fumes from engines lt1 per 10,000
  flights.
• 2006 Director for flight standards Service (J.
  Ballough)
• growing concern over numerous reports of
  smoke/fumes in cockpit/ cabin
• FAA data analysis indicates numerous events not
  being reported
• It appears as though there are numerous air
  carriers/operators who may not have reported
  these events as required by regulation. FSAW
  06-05A
• Smoke and fumes are not rare Air National Guard
  paper 1977, Rayman (AsMA), 1983, ATSB 1999,
  Ansett 2000, RAAF 2004,
• Under-reporting is occuring APH 2000, BALPA
  2003, Norwegian CAA, All UK unions BALPA, IPA
  and TGWU have written to CAA.

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Emergency checklists

• Any form of suspected contaminated air requires
  use of emergency/abnormal checklist. Is this
  happening? NO
• Checklists that cover only smoke and fire are
  inadequate.
• Fumes must be mentioned in title
• All checklists should include the following
• Use of 100 emergency oxygen as immediate first
  step.
• Smoke/fire drills need to cover smoke and/or
  fumes from air conditioning packs.
• Suspected contaminated air situations should
  require immediate use of 100 emergency oxygen /
  checklist
• Major education and training needed within the
  industry to deal with crew / industry complacency
  to fumes.

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Is contaminated air a flight safety or an OHS
issue?

• Oil fumes are more of a health problem than an
  aircraft technical defect. CASA 2003
• Toxins in the cabin air are more of an OHS
  issue and not the responsibility of the aviation
  regulator. CASA 1999
• Outside regulators, manufacturers airlines
  expertise. BAe (2000), CASA 2000
• BOTH- Australian Senate, regulations common
  sense

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UK ACARM fumes database 1/2

• lt4 of CA events are reported (BALPA 2003)
• 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 as MOR.
• 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.

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UK ACARM fumes database 2/2

• 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.
• REGULATIONS NOT WORKING

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The system is not working

• CAA / DfT in UK fail to recognize system is not
  working and deny
• Under-reporting is occuring despite all unions
  telling them.
• CAA see many events as lesser events.
• The CAA / DfT data in the UK 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

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UK Committee of Toxicity (COT) investigation..pro
blems

• COT (2007) based upon CAA evidence state
• Pilots do not have to make a mandatory entry in
  the Tech Log regarding cabin air events.
• COT focus on the fact fumes may be an irritant
  yet a typical MSDS for an engine oil says
  Toxic.
• GCAQE and many others do not see COT
  investigation as factual or helpful. UK Dept. of
  Transport (DfT) based on COT report advises no
  evidence to link fumes to health effects
  available (BBC Radio, 2007).
• Proposed DfT air monitoring not put to open
  tender and therefore not seen as independent.
• Proposed DfT testing and COT investigation
  disregarded previously known data, techniques and
  TCP findings. (e.g. Allied Signal, SAE, refer
  ACARM (appx 10)

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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.

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In summarywhat is needed

• Contaminated air detection systems must be
  fitted.
• Bleed air filtration or bleed free supplies
  needed.
• Crew education to ensure 100 emergency oxygen
  always used.
• Enforcement and education of the reporting
  system.
• Regulations such as 25.831 enforced.
• Full scale epidemiological survey of crews.
• Less toxic oils and hydraulic fluids

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Thank you for your attention.ANY
QUESTIONS?susan_at_susanmichaelis.comwww.susanmic
haelis.com