DECISIONS FURTHER TO PRE-INQUEST REVIEW HEARING HELD ON THE 21ST OF JULY 2016 – Richard Mark Westgate – 23.04.17
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AUA Offered passengers and crew after the incident no medical examination to On May 6, 2015, came aboard the Bombardier Q400 with the registration OE-LGA to search a massive smoke in the cockpit and cabin, dass die pilot Decided to turn back to Vienna - Austrian Wings reported. Now the final report of the Accident Investigation Commission has received, Which indicates did highly toxic oil fumes had Entered the cabin. flight History On 06.05.2015 the planned scheduled flights from Vienna Schwechat (LOWW) Airport Took place to the airport Innsbruck (LOWI). The pilot flying (PF) which ADOPTED on this flight the first officer while the captain on this flight, de function of the non-pilot flying (PM). Shortly after take-off from the Vienna Schwechat (LOWW) airport When the pilot operated the switches for the bleed air from Both engines (bleed 1 and 2), there was a presence of smoke, first in the cabin, and shortly thereafter in the cockpit - this circumstance is a clear indication of contamination of the cabin air through the engine oil for insiders. Nevertheless AUA spokesman Peter Thier Said a day after the incident quiet evasive towards Austrian Wings thathave "a damaged engine smoke" developed. From highly toxic oil fumes in the cabin, He Said not a word. The cabin crew, flight attendants and two flight attendants in training, smoke noticed in the passenger cabin, broke the after-takeoff announcement and immediately informed the two pilots. At the sametime, the smoke alarm activated in the toilet, Which by the cabin crew Could not be muted subsequently. The PF ordered the placement of the oxygen masks and the processing of the checklist "Fire / Smoke Flight Deck" at. Both pilots DECIDED shortly thereafter to reverse the Wien-Schwechat airport (LOWW). The PM announced shortly afterwards with a "Normal Call" in the cabin crew with respect to a briefing and dass die passenger cabin for the process "Prepared Emergency Minimum Time" should be prepared. The remaining time until the landing what the PM of about 15 minutes. It would be a normal landing in his estimation.
The pilot began emergency procedures, such as the Quick Reference Handbook (QRH) required to process. The PF stopped the climb at about 5000 ft. A flight emergency has not been declared. Compared to the air traffic control the nature of the incident via radio has been described. It was the QRH checklist "Fire / Smoke - Flight Deck" processed. However, this did not improve the situation. Also the processing of the QRH checklist "Fire / Smoke-Cabin" brought no change. Only the processing of the QRH checklist "Fire / Smoke-Unknown Source" brought an improvement in the situation. By processing this QRH checklist identified the pilot that the smoke apparently was connected with the bleed air of the RH engine. The aircraft was removed at this time about 12 nautical miles from the threshold of runway 34 of the airport Schwechat. There was a "Combined briefing" on passengers and cabin crew on the Passenger Address System (PA). The passengers responded quietly, no one panicked. The cabin crew made the "Emergency Announcement" for the passengers in English. From the cockpit was twice the command "Emergency Landing in 8 Minutes" The landing approach to runway 34 of the airport Schwechat took place via the Instrument Landing System. Specified localizer and glideslope have been complied with. The PM gave two more times, the instruction to the cabin crew "Cabin Crew, Emergency Stations". The cabin crew took their seats and buckled in. Shortly afterwards came from PM over PA command "Brace for Impact". The landing proved normal, except for the still existing smoke in the cabin. The alarmed by the duty airfield manager rescuers had taken 34 position close to the slopes and were waiting for the aircraft.
After landing the aircraft on the runway 34 has been brought to a standstill. The rescuers were able to examine the aircraft visually from the outside. Apart from slight smoke on the inside of the right engine no visible damage was evident. This was communicated by radio contact the two pilots, whereupon these decided no evacuation on the runway 34 to perform, but to control the aircraft to a designated parking position and to disembark the passengers there in the normal way (normal operation). Having arrived at this parking position, the access doors of the aircraft were immediately opened to escape the smoke and let fresh air into the cabin of the aircraft. However, the passengers could only minutes later disembarked since no passenger bus was available to the park position and were therefore more minutes of exposure to oil vapors.
When the passenger bus arrived a short time later, the passengers were taken to the terminal where the support provided by the AUA to testimony from affected passengers was poor: "The shocked passengers were not supervised, there were no offers for care or medical examinations, we had 20 minutes smoke inhaled. There was also no information. " Spilled oil was discovered still on the run Already on the apron discovered accident investigators massive oil spills in the left engine, while also addressing the AUA should have been clear at least from that date, it aboard a - by matching experts - had given incident with highly toxic substances, yet there was no information as to the passengers who had inhaled the noxious fumes. Traces of oil in the air conditioning The test report states: "After landing at the parking position, a massive leakage of engine oil was found on the right engine. Engine oil traces were on the right main landing gear, the right flap, the rear right fuselage of the aircraft and the right horizontal stabilizer of the aircraft. Apart from the aircraft was outwardly intact. After the aircraft was towed to a maintenance hangar of the air carrier, could begin immediately with a first clinical examination of the right engine. After a short time the first indication for the oil loss in the right engine was found: a crack at the intermediate compressor case (Inter Compressor Case ICC), in approximately 6 o'clock position. The intermediate compressor housing (ICC) directs compressed air from the low pressure compressor to the high pressure compressor. The intermediate compressor housing further includes the bearing recesses of the bearing # 3 and # 4. "In further studies eventually traces of oil in the right bleed air line and the air conditioning were discovered. Manufacturer itself indicates toxic substances in the engine oil On representational aircraft an engine oil type Mobil Jet Oil II was used investigation report, which contains toxic substances. Thus, the manufacturers themselves in a separate sheet under the item entitled "Health and Safety" to the following: "WARNING! While no significant adverse effects on health are expected When properly handled and used, this product contains tricresyl phosphate
(TCP) Which, if taken internally, can cause paralysis. " Inspection body has problems of "Aerotoxic syndrome" towards The experts examined department VERSA go to the problem of contaminated with engine oil cabin air an "engine oils, hydraulic fluids and other materials that are used in aircraft construction and operation, have in common that in the formulations of these substances, toxic, so for the people toxic chemicals, here especially from the group of organic phosphates, are. Thus, in the engine oil of modern aircraft engines, among other things, the chemical tricresyl (TCP). This material is used especially because of its excellent properties as plasticizers for plastics (seals, O-rings, ...), as a lubricant additive for engine oil and a noncombustible additive for hydraulic fluids. With its special properties TCP is an ideal ingredient for lubricants to ensure the optimum and smooth running of the rotating parts inside modern aircraft engines, even at very high temperatures and prolonged exposure. Allen engine oils available on the market is at levels between three and up to five percent, depending on the manufacturer, added TCP. As one of the possible toxic agents that can cause peripheral neuropathies of the nervous system, is, inter alia, the ortho isomer of TCP in the foreground. Among the known symptoms after such oil vapor incident to passengers and crew members include anxiety, reduced performance, speech disorders, irritated mucous membranes, burning eyes, coughing, salivation, increased bronchial secretion, bronchospasm (spasm of the bronchial muscles), difficulty breathing, shallow breathing, including paralysis and sudden onset of tremors in the limbs, nausea, vomiting or severe (migraine) headaches. " Crew and passengers were given no medical assistance Although the AUA almost immediately after the incident, the explosive must have been clear, loud VERSA under remained available for medical care for crew and passengers. Literally, to the investigation report: "After leaving the aircraft by passengers and crew of any medical examinations or treatments were available." demanded investigations The VERSA writes under "security recommendations" explicitly states that the "effects of contaminated cabin air in aircraft on the human body in a timely manner, shall be fully and independently investigated to from the results gained from solutions for the protection of passengers and crew members (worker protection ) identify and implement mandatory ".
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