Explaining Environmental Issues for the Allied Pilots
Association
Presented by
Captain Eric Tellmann
Spirit-ALPA
ALPA-Aeromedical MEC
Environmental Standards
Committee Chairman
Topics of Discussion
•
July 17th 2015/ WGN News reports
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What are Cabin Air Quality Issues
•
Non-routine Events
•
Under Reporting
•
Education-ICAO Training Circular 344
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Includes ensuring that pilots and CC know how to distinguish between fumes that likely
matter (vents), and fumes that don’t (in-cabin), use common terms, and share clear
communications
•
Checklists and Prevention
•
Medical Effects Observed in Crew Members
July 17th 2015 ORD-BOS
What are Fume Events?
Pyrolyzed engine oil sometimes contaminates
aircraft environmental control systems,
exposing aircraft occupants to oil fumes
containing toxic chemical constituents.
Exposure to oil fumes has been reported to
cause both acute and chronic neurological and
respiratory symptoms, and has been
documented to compromise flight safety.
Neither the frequency nor the causes and
characteristics of fume events have been welldescribed, either at individual airlines or
industry-wide.
Some are visible - most are not
•
41st International Conference on Environmental Systems 17 - 21 July 2011, Portland, Oregon American Institute of
Aeronautics and Astronautics
History of Fume Events
Smoking ban enacted on aircraft in
the mid 90’s –smoking hid the fumes
Rewind to 1939 and you can find books/papers published
by military and industry researchers in the United States,
all concerned about engine oil fumes that were reported
In 2001 EPA bans household use
to contaminate the outside air component of the aircraft
of most organophosphates in part
ventilation supply.
because of human health
• Armstrong, 1939
• Boeing, 1953
• Reddall, 1955
1995 USAF study finds TCP heated to high temps resulted
• Treon et al., 1955
in changes to compounds, increasing neurotoxicity
1967 ESSO study tested oil on animals
and determined the cause of death was
severe irritation to respiratory tract
Armstrong, 1939
Principals and Practice
of Aviation Medicine
Social Media increases awareness but can also
create misconceptions
One example…
June 2015 headline after four Alaska
Airlines FA sued Boeing
8
10
What do the manufacturers say about
this?
The Boeing Papers
Per ISI Ref: 21.00.00018 A/C Type: A318 A319 A320 A321 Topic: First Issue
Date: 07-NOV-2013 Part Number: Last Publication Date: 08-NOV-2013
Airbus claims engine oil will leak into the bleed system on the aircraft and
cause a musty smell in the cabin.
In a separate letter sent to airlines Dr.
Andreas Bezhold, with Airbus, also claims
that there are no associated health
medical risks associated with fume
events.
Airbus also stated
Per SAE AC9
SAE AC9 2015 Dr.Andreas BEZOLD, Airbus
• Bad smell was reported regularly during production flights on
one specific Airbus aircraft type during specific flight phase
• Flight Test Engineers sometimes reported about physiological
symptoms (Irritation of eyes, respiratory system,…)
• In-Flight Cabin air Analysis project was launched to determine
contamination pattern on aircraft during smell events
• Evaluation of contaminants with regard to their physiological
impact
• Possibly identification of root cause by the nature of
contaminants and their appearance depending on aircraft
system parameters
Outside Exposures
On the Ground
• Exhaust from ground support equipment
• Exhaust from jetway equipment
• Exhaust fumes from other aircraft
Inside the Cabin
•
•
•
•
•
•
Ozone (dep. on season, altitude, and latitude)
ECS contaminants
Residual cleaning materials
Lavs/blue fluid
Pesticides sprayed in the cabin
Passengers and crew
• Bioeffluents, viruses, bacteria, luggage,
food, etc.
Non-Routine Events
ECS Contamination-bleed air contamination
• Engine and APU lubricating oils
• Hydraulic fluids
• De-icing fluids
What’s in the fumes?
Hazardous ingredients singled out on SDS:
Tricresyl phosphates (TCPs; neurotoxic, reproductive toxin): 2.2 – 5.6%, by weight (all engine
oils)
Trixylynl phosphates (TXPs; neurotoxic, reproductive toxin): 0.1 – 1%, by weight (ExxonMobil
oils)
Tributyl phosphate (TBP; eye/respiratory/skin irritant, endocrine disrupter): ≈ 20%, by weight
(Skydrol 500B-4 hydraulic fluid); also ≈70% dibutyl phenyl phosphate and butyl diphenyl
phosphate
Phenyl naphthylamine (PAN; sensitizer and asphyxiant): 0.1-1%, by weight (all engine oils)
Hazardous constituents of fumes (some are ingredients, some are generated upon heating)
not singled out on SDS (carbon monoxide, acrolein (irritant), formaldehyde, benzene-based
compounds, etc.
Excerpt from Mobil Jet II health hazard
warning on safety data sheet:
POTENTIAL HEALTH EFFECTS This product is not expected to produce adverse
health effects under normal conditions of use and with appropriate personal
hygiene practices. Product may decompose at elevated temperatures or under fire
conditions and give off irritating and/or harmful (carbon monoxide)
gases/vapors/fumes. Symptoms from acute exposure to these decomposition
products in confined spaces may include headache, nausea, eye, nose, and throat
irritation. High-pressure injection under skin may cause serious damage.
Mobil Exxon Also Stated
Mobil does not consider accidental exposure to oil
vapors in aircraft cabin to be “Normal Use”
Mobil Jet Oil II Consists of
Synthetic esters based in a mixture of 95% C5-C10 fatty acid esters of
Pentaerythrivol and dipentaerythritol;
5.2% of the organophosphates tricresyl phosphates (TCPs)
(phosphoric acid, tris (methylphenyl) ester, CAS number 1330-78-5
1% N-Phenyl-alpha-naphthylamine (PAN) (phenyl-alpha-naphthylamine; 1Naphthalenamine, N-phenyl, CAS Number 90-30-20, PAN contaminants
Various reported mixture of 0.1%-1% octylated diphenlamines: Benzamine, 4-Octyl-N(4Octylphenyl), Dioctyldiphenylamine (DODPA) (CAS Number 101-67-7); N-Phenyl
Benzeneamine, reaction product with 2,4,-Trimethylpentene/diphenyl amines alkyls
(CAS 68411-46-1)
NRC (National Research Council) Recommendations 2001
FAA should require a CO monitor in the air supply ducts to passenger cabins and establish standard operating
procedures for responding to elevated CO concentrations.
Kansas State University Research suggested that there are 5.3 fume events over the 24,000 flights a day.
That’s 1,955 A year
At the 2016 ALPA Safety Forum, the FAA Head Flight Surgeon stated only six bleed air events
per year are reported to the FAA.
FAA does not
require bleed air
sensors
(Recent model, onboard
chemical sensor)
Where are the errors in this?
Smoke events are required to be reported with each occurrence except, fume events not accompanied with
visible smoke are only required to be reported when associated with a mechanical discrepancy AND only if
inflight (not at the gate) UNLESS airline says flight safety could have been compromised. So, if fumes sourced
to overservicing (for example) on the ground or inflight, technically does not have to be reported to the FAA.
Most pilots assume the dirty sock smell is a moldy filter
when in fact the used turbine oil specifically MJII smells
like dirty old socks.
Combined, lack of training, poor understanding, misconceptions,
under-reporting, and weak FAA regulations leave big gaps and
enable the FAA to understate the extent of the problem.
Why is there under reporting?
•
Design/operating FAA regulations are
inadequate, and those FARs that could
help (like reporting rules) are poorlyworded and airlines don’t comply with
them consistently.
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Lack of training and education amongst
pilots, FA, maintenance workers
(including misinterpretation of what the
smells actually are).
•
Emphasis on securing on-time
departures, sometimes at cost of
safety/health.
•
Personal opinions - It never bothered
me before so what's the big deal?
Misconceptions and Facts
Mistake to think that “just old airplanes smell.” It’s not the airplane – it’s oil. Also, fumes happen on brand
new aircraft, too.
Misconception that dirty socks smell is “just” a “moldy filter” or a “bad water separator.” Airline
maintenance manuals and manufacturers consistently recognize that it’s pyrolyzed oil fumes.
Notion that “tricresyl phosphates are all I need to worry about in oil fumes” is false. There are actually 800
different chemicals that can be produced during an aircraft fume event, including CO (carbon monoxide).
Fact that potential for oil fumes in any cabin/flight deck supplied with bleed air. During the early years of
aviation until the mid 90’s, fumes likely camouflaged by cigarette smoke.
Fact that social media enables information sharing within and between airlines, and globally.
ICAO Training Circular 344
In November of 2015 ICAO published training circular 344 GUIDELINES ON
EDUCATION, TRAINING AND REPORTING OF FUMES EVENTS.
Per ICAO-Operator Should Address
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Sources and types of on board fumes/odor
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Odor descriptors to recognize the presence of oil and hydraulic fluid fumes
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Potential for impairment
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Procedures to apply in fume events; and
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Reporting of fume events
How to Train for Fume Awareness
Develop operator procedures as to how the events should be conducted with company
procedures.
Incorporate class room training referencing ICAO Training Circular 344
Train Management, Pilots, Flight Attendants, Mechanics, Dispatchers, and any other personnel
directly involved with the on board operations of the aircraft on the operator procedures.
Incorporate simulator training for pilots using fumes based checklist
for awareness and isolation of affected aircraft systems
• Most aircraft checklist do not address oil based ECS fumes
Flight Crew Responsibilities
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Use of oxygen
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Application of operator procedures
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Communication with flight attendants and maintenance
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Post-event procedures
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Applicable documentation
How do contaminants get into the bleed system thru the engine and/or APU?
How do contaminants get into the bleed system? (cont’d.)
Component Failure
• Oil pressure switches and other components
• Engine bearing and seal failures
• De-oiler seals
• Maintenance irregularities
• Design deficiency
Over servicing
• It is recommended to only fill to the 2/3rds mark within
the specified time frame of engine shutdown
• Spilling
• Oil gauge can be misread if APU not shut down properly
(Airbus)
Dr. Susan Michaelis Fluid Sealing 2016
What happens when a bleed system is contaminated?
Once oil enters the ECS system if the affected PACK is not isolated, then the ECS system will continue to
produce fumes. Once the affected PACK is isolated and shut off, then fumes should dissipate from the
cabin.
Engines typically contaminate the associated pack, in normal operations
Oil fumes sourced to the APU can contaminate a single pack, and in some cases can contaminate both
packs, depending on airflow and rates of leakage even if the APU is not running. This is due to the fact that
the APU can leak oil at the gate, at such a low level that is undetectable to smell. This oil can accumulate in
the cold and lower parts of the bleed system until a change of pressure or temperature exists in the ECS,
most commonly associated with HP and IP valves changing position and changing from a heating to a
cooling mode whereas the fumes will generate. So, APU-sourced oil can enter the bleed system even when
the APU isn’t operating.
Most Smoke/Fumes checklist
do not correctly address oil
based ECS fumes. At least
one airline has created their
own version...
Communication between the crews
To have a successful checklist procedure effective, the flight attendants and pilots must have clear
communication between the front and back. With normal system configuration, on Boeing aircraft, PACK 1
ventilates the cockpit and forward cabin, and PACK 2 ventilates the mid and aft cabin. This fact is helpful in
determining the possible source of fumes. Re. fumes in the cabin, flight attendants should be trained to relay
information to the pilots re. general source (vents or in-cabin), odor description, and location in cabin (e.g.,
worse in back, same throughout, etc.) should be relayed to the cockpit so the pilots have all the information
needed to make a well-informed decision as to how to isolate the possible source.
When crews do not communicate with each other, it makes it
more difficult to effectively troubleshoot the system, with
potential health/safety consequences.
Lets look at the medical part of how this affects the crews.
Chemicals in fumes that displace oxygen from
hemoglobin protein in red blood cells
Carbon monoxide (CO)
N-Phenyl-alpha-naphthylamine (PAN)
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Hypoxia
No matter what the cause or type of hypoxia that pilot experience, the signs,
symptoms, and effects on flying skills are basically the same. Hypoxia is easy to
succumb to because the human body does not have an effective warning system
against the threat. Many incidents and some accidents are "officially" attributed to the
pilot's inability to detect hypoxic conditions, with the result that the pilot becomes
unsafe because of compromised skills and judgement. And the onset can be
insidious.
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FAA Training Document-Airman Education Training Programs
Hypemic Hypoxia
This type of hypoxia is caused by the reduced ability of the blood to carry
oxygen. To the pilot, this means that, even though there is an adequate supply
of oxygen to breathe, the blood's capacity to carry the oxygen to the cells has
been impaired. There are a variety of reasons for this to happen. Anemia,
hemorrhage, hemoglobin abnormalities, sulfa drugs, nitrites, and carbon
monoxide interfere with the ability of the blood to carry oxygen, reducing the
amount of oxygen the blood can carry to the cells. The most common cause for
hypemic hypoxia in aviation is when carbon monoxide is inhaled because of
aircraft heater malfunctions, engine manifold leaks, or cockpit contamination
with exhaust from other aircraft. Hemoglobin bonds with carbon monoxide 200
times more readily than it bonds with oxygen.
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Tricresyl phosphates in oil fumes
TCPs are organophosphates (OPs). OPs is a family of chemical compounds developed largely for
use as pesticides and nerve agents (chemical warfare). Most OPs are neurotoxic.
TCPs are additives in ALL aviation engine oils used on the commercial fleet globally. They reduce
wear on the engine and stabilize engine temperature.
However, they are not intended for consumption. SDS for TCPs report that acute symptoms include
stomach cramping, muscle aches, and sinus congestion. May be mistaken for food poisoning or flu.
TCPs can also result in delayed-onset “OPICN” (organophosphate-induced chronic neurotoxicity).
TCPs inhibit butyl cholinesterase (important enzyme). After exposure to oil fumes, a Spirit Airlines
Captain and First Officer were diagnosed with “Effects from a cholinergic drug.”
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This system has a primary goal of survival and works through
reflexes. We can consciously try to control our nervous system,
but we cannot override reflexes. Even unconscious, our reflexes
are still at the ready.
When a threat exists our nervous system responds with various
physiological responses in a way that is most appropriate to a
threat.
Reactive chemical gases and vapors that can severely change the structures of the
proteins, lipids, DNA, and other biomolecules, resulting in a loss of protein
function, DNA, and tissue death of the airway.
39
UK research by Michaelis of crews indicates that symptoms can appear
delayed by 24-48 hours and, for neuro, even longer (consistent with OPICN)
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Symptoms
• Mild Poisoning: Initial symptoms are usually fatigue, dizziness, and
sweating. These symptoms may also be accompanied by headache,
inability to concentrate, cognitive dysfunction, weakness, anxiety, tremors
of the tongue and eyelids, miosis (pupil constriction), and tightness of the
chest.
• Moderate Poisoning: In addition to the initial symptoms, the following
symptoms may result: salivation, lacrimation, abdominal cramps, nausea,
vomiting, slow pulse, bradycardia, fall in blood pressure, and muscular
tremors.
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Symptoms
• Severe Poisoning: Pinpoint and non-reactive pupils, muscular
twitching, wheezing, increase in bronchial secretion, respiratory
difficulty, cough, pulmonary edema, cyanosis, diarrhea, loss of
sphincter and urinary bladder control, tachycardia, elevated blood
pressure, convulsions, coma, heart block, and possibly death.
• Acute and Chronic Exposure: Generally, the interval between a
single acute toxic exposure to organophosphorus ester and onset
of symptoms is very short, usually ranging from 5 to 60 minutes.
Some individuals, however, may not develop the symptoms of
poisoning until 24 hours after exposure.
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If a crew is exposed to a possible fume event for an extended period of time and either
cannot or does not take action to stop or prevent it, please look for signs of symptoms if
able.
Common signs of carbon monoxide poisoning
Acting lethargic, Confusion, Slurred speech, Blurred vision, Dull headache, Weakness,
Dizziness, Nausea or vomiting, Shortness of breath, Confusion, Blurred vision, Loss of
consciousness
6-48 hours after a fume event common signs
of organic phosphate poisoning appear.
Acute and Chronic Exposure: Generally, the
interval between a single acute toxic exposure
to organophosphorus ester and onset of
symptoms is very short, usually ranging from 5
to 60 minutes. Some individuals, however, may
not develop the symptoms of poisoning until 24
hours after exposure.
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Dr. Clem Furlong
University of Washington
Research Professor of Genome
Sciences and of Medicine
Currently developing a blood test that will enable crews to determine if
they’ve inhaled oil fumes onboard. A blood test specific to the types of
TCPs in oil fumes is important to enable prompt recognition of an
exposure and suitable medical care.
In 2015, ICAO recognized potential flight safety impact of exposure to fumes
but flight safety benefit in preventing exposure. Airlines that proactively work
to prevent exposure to oil/hydraulic fumes onboard will be recognized as
leaders in clean air onboard and improved flight safety.
Possible Solutions and Discussion?
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Pall Filters – developing bleed filters for multiple aircraft types, currently used in
the DHL 757
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Peter Schiff – Developed a non-bleed conversion currently used on 20 Turbo
commander aircraft.
•
•
•
Patented
Prevents toxins from the cabin pressurization air
Claims 6-8% fuel savings
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French company, Liebherr, is also developing
non-bleed option
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Ultimate solution is non-bleed aircraft – buy the B787!
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Tell Boeing you want non-bleed option on B737!
What to do for the short term
1. Implement ICAO training
2. Implement a Fumes checklist
3. Install Carbon HEPA filters on
recirculation fans
4. Implement medial care
standards for affected crews
and passengers
What to do for the long term
1. Find Bleed filters for your
aircraft
2. Tell the manufacturers to
design future aircraft like the
787. We’re the customer, they
will build what we want.
References Cited for this presentation
• EPA “Memo titled: ‘Guidance: Waiver criteria for multiple-exposure inhalation toxicity studies,’” HED
SOP2002.01, Office of Prevention, Pesticides, and Toxic Substances, US Environmental Protection
Agency, Washington, DC. Aug. 15, 2002
• Michaelis, Susan (2010) Health and Flight Safety Implications from Exposure to Contaminated Air in
Aircraft. The university of New South Wales: Susan Michaelis
• IFAPA 2013 Cabin Air quality 13SAB006 The Global Voice of pilots
• Health Standards. American Industrial Hygiene Association, 1995. ISBN 0-932627-34-X
• Measurement of Airborne Chemicals on Aircraft during Industrial Flight Tests Getting to grips with
odour SAE AC9 2015 Dr.Andreas BEZOLD, Airbus
• Per ISI Ref: 21.00.00018 A/C Type: A318 A319 A320 A321 Topic: First Issue Date: 07-NOV-2013 Part
Number: Last Publication Date: 08-NOV-2013
• Murawski, JT “Case Study: Analysis of Reported Contaminated Air, Events at One Major US Airline in 200910 ” 41st International Conference on Environmental Systems 17 - 21 July 2011, Portland, Oregon American
Institute of Aeronautics and Astronautics, AIAA (2011)
• Michaelis, SM. Presentation at the 23rd International Conference on Fluid Sealing 2016 Manchester UK 2nd3rd March 2016 (2016)
• AIHA: Odor Thresholds for Chemicals with Established Occupational Health Standards. American Industrial
Hygiene Association, 1995. ISBN 0-932627-34-X (1995)
• Lipscomb, J., Walsh, M., Caldwell, D. et al. Inhalation Toxicity of Vapor Phase Lubricants. AL/OE-TR-19970090. US Airforce Armstrong Laboratory, Occupational and Environmental Health Directorate, Toxicology
Division, Wright Patterson Airforce Base, Ohio (1995)
• Levenson, T. and Shelanski, M. Report-Synthetic lubricants. Industrial Biology Laboratories Inc. Sponsored
by Medical Research Division, Esso Research and Engineering Company (1967).
• Shehadi, M; Jones, B; Hosni, M “Characterization of the frequency and nature of bleed air contamination
events in commercial aircraft,” Indoor Air, 2016 Jun; 26(3):478-88. doi: 10.1111/ina.12211. Epub 2015 Apr 25.
(2016)