Mr. David Miller
Acting Chief Inspector of Air Accidents
Air Accidents Investigation Branch
Berkshire Copse Road
Wednesday, 2nd November 2016
Dear Mr. Miller
BA286 Airbus A380 In-flight diversion to Vancouver due to reported ‘toxic fumes, toxic gas like fumes’
I was informed yesterday by one of your Operations Officers, Ms Irene Arthur, that the Air Accidents Investigation Branch (AAIB) has decided not to investigate the inflight diversion of British Airways flight BA286, an Airbus A380-800 registered G-XLEB, which was operating San Francisco to London Heathrow and diverted into Vancouver last week. The crew stated to Air Traffic Control (ATC) using the call sign ‘Speedbird 6 Bravo’ they had toxic fumes. toxic gas like fumes.’ The relevant audio can be heard from time 03:07 at the following YouTube link:
I am a former British Airways (BA) Captain, Health and Safety representative for BALPA and former co-chairman of the Global Cabin Air Quality Executive (GCAQE). I have investigated the issue of contaminated air on aircraft for over 15 years and briefed the European Aviation Safety Agency (EASA) extensively on this issue in 2015. Last year, I was awarded, by the British people, a British Citizen Award for Services to Industry (BCAi) for my work on this issue to date.
I am writing to you as numerous aspects of the BA286 diversion flight would indicate a potential exposure of 432 people to pyrolised synthetic jet engine oil, hydraulic fluids or some other chemical. The testimony of the crews and passengers I have received, the inflight ATC audio transcript and the feedback from Transport Safety Bureau – Canada (TSB) and others, all indicate a potential significant exposure for those onboard. Some of the crew I understand are still signed off work sick, a week later by their doctors.
TSB-Canada has informed me that it will not be investigating the event any further and neither will the AAIB. This was a British registered aircraft carrying many British citizens including young children and pregnant women. The commander of the aircraft used emergency oxygen and numerous cabin crew were on emergency oxygen, unable to carry out their duties.
I understand that Centre for Disease Control (CDC) and the University of Washington (UW) in Seattle are willing to screen the crew members blood to look for any evidence of an exposure to neurotoxins. Crew unions and the Royal Australian Air Force (RAAF) have spent nearly 15 years supporting the research for a blood test and preparing the protocols to test for exposure to the aryl phosphates in synthetic jet engine oils. All the AAIB needs to do is ask them to do it.
CDC will be able to check for exposure to phosphate compounds that are known to be present in aryl phosphates and UW will very soon be able to look at the proteins decorated by these exposures and potentially confirm not only an exposure but time of exposure. This would be an invaluable report for any air accident team to have to help them better understand any potential contaminated air exposure event. Do you think this would be a sensible option for the AAIB to ask CDC and UW to do this work? There is no cost to the UK tax payer.
The AAIB has been one of the leading air accident investigation teams in the world. As you know the AAIB have twice recommended the fitting of contaminated air detection systems to commercial jet and turbine aircraft so that crews can know when the air is contaminated. DHL have fitted activated carbon filtration systems to even protect their crews from exposure to jet engine oil fumes on their Boeing 757, many of these are previous BA aircraft. The Swiss Aircraft Accident Investigation Bureau, in their report into the serious incident on HB-IXN in 2005, stated that:
‘The medical examination of the co-pilot after the flight showed that during the flight a toxic exposure took place.’
You may recall the serious incident BA had on the 7th November 2000. It was a Boeing 757 (G-CPEL), operating BA 815, CPH LHR (CAA Occurrence Report: 200008363). The crew forgot to slow aircraft during approach until reminded to do so at 3.7 mile from touchdown by ATC. The report concluded that the crew were unaware that they were becoming partially incapacitated due to oil fumes. There are hundreds of such incidents around the world. In fact in an internal Boeing email from 2007 a senior engineer stated:
“Bottom line is I think we are looking for a tombstone before anyone with any horsepower is going to take interest.”
These events clearly show the serious flight safety implications that pyrolised oil fumes can have on flight safety. If a crew divert due to oil fumes and fail to use emergency oxygen, what happens if they go on to have a serious problem to deal with? This point was made very clear by the AAIB investigating an incident on a BA aircraft on 7 September 2003 (G-CPER), the aircraft suffered oil fumes after take off from Heathrow and diverted to Gatwick. On approach the crew had a flap problem. Thankfully the crew both used oxygen as the AAIB report commented:
“The flight crew made a positive decision to action the emergency checklist and don their oxygen masks in a timely manner. This was a prudent course of action, given that experience shows that pilot’s well-being and judgement can be affected by exposure to engine oil fumes. Had they not taken this action, the subsequent handling difficulties on the final approach to London Gatwick could have been further compounded, increasing the degree of risk.”
Yet 13 years later, under-reporting is still significant, a fact the FAA acknowledged a decade ago and aircraft still have no form of detection system to warn when the air is contaminated, yet under the FAR 25.1309c and CS 25.1309c it states:
(c) Warning information must be provided to alert the crew to unsafe system operating conditions, and to enable them to take appropriate corrective action. Systems, controls, and associated monitoring and warning means must be designed to minimize crew errors which could create additional hazards….
I would suggested contaminated air is a clear sign of a system failure yet there are no warning systems fitted.
Surely events of the past should be learnt before an incident becomes a serious accident? The US aviation industry has been aware of this issue for 6 decades as highlighted in the 2011 PhD by Doctor Susan Michaelis “Health and Flight Safety Implications from Exposure to Contaminated Air in Aircraft.“
It is possible the cabin crew impaired on BA286 might not have been able to carry out their emergency duties should the aircraft have needed to have been evacuated on landing. For so many crew to have been impacted so significantly in flight, clearly something happened on board. Mass hysteria or an exposure to chemicals such as pyrolised jet engine oil fumes? I urge the AAIB to conduct an independent investigation and support CDC and UW with a crew blood analysis.
Should you require any further information please do not hesitate to contact me.
I attach the Swiss 2005 air accident report referred to above and a published survey of BALPA pilots from 2003, a report that highlighted under-reporting of contaminated air events which may be helpful.
I am copying in a few of the MPs and interested parties who have expressed an interest in these issues including Mr. Tobias Ellwood MP. Mr Ellwood was informed by Exxon Mobil some years ago that they are unaware of any published inhalation toxicity data for exposure to synthetic jet engine oil fumes. If there is no published data how can any exposure to contaminated air, especially to the unborn be deemed safe?
Captain Tristan Loraine BCAi
Phone: +44 1403 734550
Cell: +44 7968 213862
We look forward to publishing the AAIB response, in due course.