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Summary

Summary

The crew carried out the takeoff in the British Aerospace Plc BAe 146 (BAe 146) with number-4 engine air bleed selected on, and engine numbers 1, 2 and 3 and the auxiliary power unit air bleeds selected off in compliance with an item in the discrepancy log. Shortly after take off, at approximately 700 ft above ground level, the copilot switched on the remaining engine air bleeds and both airconditioning packs. Shortly after selecting engine anti-ice on, the pilot in command (PIC) asked the copilot if he could smell fumes. The copilot agreed that he too had detected a smell. The engine anti-ice system was then switched off.

A short time after commencing the cabin service, a flight attendant (FA) called the flight deck and informed the PIC of fumes in the cabin and that they were particularly bad near the rear of the cabin where another FA had donned an oxygen mask. This mask was of the diluter type that supplies a mixture of the incoming oxygen with the ambient air that is then delivered to the user. The copilot then indicated to the PIC that `he felt he should go onto oxygen' and donned an oxygen mask, but the PIC did not feel he needed to perform the same action at that time.

The PIC later stated that he did not don his oxygen mask at this time, as he was considering if the fumes were oil related in accordance with a notice to pilots (NOTOP) from the operator. This NOTOP required the PIC to make a diagnosis as to the source of contamination `wherever it is safe and practicable to do so'. The PIC's findings were required by the operator to determine the level of response required to later rectify the problem and return the aircraft to service.

The PIC stated that the aircraft type had a history of fumes related problems and not donning his oxygen mask was a normal practice for himself and, he believed other aircrew employed by the operator. He said `most smells and odours were considered the normal environment of the day to day operation of the BAe 146' and he would have discontinued his NOTOP diagnostic action if he perceived a flight hazard issue and would have reverted to the emergency checklist action. He also stated that the copilot, being on oxygen, could confirm a successful isolation procedure by occasionally removing his mask and comparing pure air with the ambient air of the flight deck.

This was at variance with the emergency checklist for SMOKE/FUMES/FIRE IN COCKPIT/CABIN. This list takes priority over any other action. The first item on the checklist is `Oxgen masks and goggles...Flight crew don, check 100%'. The imperative in relation to fumes events was also highlighted in an all operator message (AOM) from the manufacturer, which states in part `pending the definition of any necessary corrective actions, oil leaks and cabin/flight deck smells must be regarded as a potential threat to flight safety and not just a nuisance'.

The copilot completed fault isolation checks that appeared to improve the air quality on the flight deck. The PIC then asked the FAs if they could come to the flight deck so that he could better assess the situation in the cabin. The FAs came forward in turn, opened the flight deck door and entered. This action was at variance with the operations manual actions for flight attendants in the event of smoke/fumes in the cabin. The manual stated that, in the event of smoke/fumes, the FAs were to inform the PIC via the intercom and were not to open the flight deck door.

In his original report, the PIC stated that `each time when they opened the flight deck door, we noticed that the odour intensified'. The FAs' cabin crew reports to the operator also stated that the odour and fumes were still evident in the passenger cabin during the remainder of the flight. The PIC described the odour to be unlike any odour previously encountered and then decided the safest option was to return to the departure airport.

The incident operating crew underwent medical examinations that evening as directed by the operator after the event. The PIC stated that the medical practitioner they visited told him she knew very little about the effects of odours on crew and was unaware of any specific blood testing requirements for such an event. Medical testing information printed by the aircraft manufacturer in Service Information Letter (SIL) 21/45 Issue Number 1, dated January 2001, details specific test requirements. The PIC stated that it was sometimes difficult to find a medical practitioner at short notice (especially late at night) who was familiar with the required testing procedures.

After advising the medical practitioner that he was unsure if he would be able to work the following day, the PIC was given a medical certificate excusing him from flight duties for the following 24 hours. Even though he donned his oxygen mask, the copilot was similarly affected and was also excused from flight duties for the same period as the PIC. The operator reported that the remaining crew did not exhibit any residual effects from the incident.

A maintenance investigation by the operator included compliance with the latest airworthiness directive and service bulletins. All engines and the auxiliary power unit were checked. The airconditioning regenerative ducting and the delivery ducting to the rear cabin were also dismantled and inspected. That investigation determined that the number-3 engine was the likely source of the fumes and the engine was changed. The aircraft was returned to service with subsequent operating crews reporting no further fumes problems.

 
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