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.December 2007
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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.www.gcaqe.org
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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 taken from a wide variety of sources
• Data confirms there is a problem.

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ACARM data taken from

• 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

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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.
• 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.

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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.

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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)
• 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

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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 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
• Inhalation toxicity testing for exposure to
  heated jet engine oils has never been done.
• NYCO oils do not contain TCP e.g. Tubonycoil
  600

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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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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.

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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

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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

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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
• Crews are losing medicals/ careers

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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

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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
• Worksafe Responsibility of CASA
• BOTH- Australian Senate, aviation OHS
  regulations.. and common sense!

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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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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

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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

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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.

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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.

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Solutions

• DO EXIST
• Its time to implement them
• We can fix this problem together

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Thank you for your attention.Aviation
Contaminated Air Reference Manual
-ISBN9780955567209 susan_at_susanmichaelis.comwww.s
usanmichaelis.com