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GCAQE Presentation


									Oil and hydraulic fluid contamination of aircraft air supplies.

An overview of the health and flight safety implications.
10 October 2007- RAeS

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

The 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.

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.

ACARM data taken from:
• Industry documents • • • • • • • • • • • • •
Government data Scientists & doctors Aircrew & passengers Media Bureaus of air safety Industry meetings & conferences

wide variety Published papers Surveys Union reports Defect reports Regulator reports Medical reports Legal / insurance reports

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

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.

• • • •
• •

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.” 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……



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
• „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.

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.‟ from inhalation of synthetic oil fumes… is definitely warranted.‟

• „Further investigation into the potential hazards

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.

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 >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


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


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

Identifying contaminated air exposure
Contaminated air descriptions include:

• • • • •

Oily Locker room Wet dog Hot oil Pungent

Sweaty-sock-like Aromatic (like benzene) Acrid Burnt oil Dirty Socks

Descriptions will vary

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).

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)



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

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.

• • • • •


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

Medical effects
Crew And Passenger „Aerotoxic Effects‟ Following Inhalation Of The Heated Products Of Synthetic Jet Engine Oils And Hydraulic Fluids Can Be:


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

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

What are the overall health concerns?
• Short and long-term health effects are occuring. • Effects seen are supported by published papers, chemical •
– – – – 86% acknowledge exposure to contaminated air. 57% report short, medium or long-term health effects. 25% report medium to long-term health effects. >8% early medical retirement or loss of medical.

data… 2007 BAe 146 pilot health survey: preliminary data (n=242)

• Crews being diagnosed / misdiagnosed with MS, Parkinsons, •
CFS, MND, Alzheimer's, depression, PTSD, bipolar disorder… Term ‘Aerotoxic Syndrome’ to be utilized (APH 2000).

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

IS contaminated Air a Flight safety Risk?


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)

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.


Is contaminated air rare?
• FAA: Contaminated air events/smoke/fumes occur:
– 2002: once per 3.59million departures. – 2005: smoke or fumes from engines: <1 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.

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:

• Major education and training needed within the industry to
deal with crew / industry complacency to „fumes‟.

– 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

Is contaminated air a flight safety or an OH&S 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 OH&S issue and not the responsibility of the aviation regulator.” CASA 1999 “Outside regulator‟s, manufacturer‟s & airlines expertise.” BAe (2000), CASA 2000


BOTH- Australian Senate, regulations & common sense

UK ACARM fumes database


• <4% 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.

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.


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

SOURCE ACARM Database CAA (on ACARM database) HOL HOC

YEAR - 2005 265 127 35 78

UK Committee of Toxicity (COT) investigation…..problems
• 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)

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.

In summary…what 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………

Thank you for your attention. ANY QUESTIONS?

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