IATA - CABIN HEALTH IATA - CABIN HEALTH CONFERENCE OCTOBER CONFERENCE OCTOBER 20082008

Captain Susan MichaelisCaptain Susan Michaelis

Aviation Contaminated Air Aviation Contaminated Air Reference ManualReference Manual

An overviewAn overview

Susan Michaelis -Susan Michaelis -

• Former Australian Airline Pilot.(1986-1997) –Ill Former Australian Airline Pilot.(1986-1997) –Ill health retiredhealth retired

• Winner 1987 CASA Sir Donald Anderson award - Winner 1987 CASA Sir Donald Anderson award - Best academic meritBest academic merit

• Commenced research 1997 (MSc 2002)Commenced research 1997 (MSc 2002)• Head of Research - Global Cabin Air Quality Head of Research - Global Cabin Air Quality

Executive (GCAQE). Executive (GCAQE). • PhD research student at the University of New PhD research student at the University of New

South Wales in Sydney, Australia.South Wales in Sydney, Australia.• Author of the Aviation Contaminated Air Author of the Aviation Contaminated Air

Reference Manual (2007). (ACARM)Reference Manual (2007). (ACARM)

Aviation Contaminated Air Aviation Contaminated Air Reference Manual (ACARM)Reference Manual (ACARM)ISBN:9780955567209 ISBN:9780955567209

• Published in 2007.Published in 2007.• 1st time data has been collated.1st time data has been collated.• 844 pages of key information.844 pages of key information.• Aviation industry data from 1953 – 2007Aviation industry data from 1953 – 2007• Data is fully referenced / widely sourcedData is fully referenced / widely sourced• Covers all main issues from incidents, Covers all main issues from incidents,

monitoring, health effects and flight safetymonitoring, health effects and flight safety

ACARM data taken from:ACARM data taken from:

• Industry documents -Industry documents -wide varietywide variety

• Published papersPublished papers

• SurveysSurveys

• Union reportsUnion reports

• Defect reportsDefect reports

• Regulator reportsRegulator reports

• Medical reportsMedical reports

• Legal / insurance Legal / insurance reportsreports

• Government dataGovernment data

• Scientists & doctorsScientists & doctors

• Aircrew & passengersAircrew & passengers

• MediaMedia

• Bureaus of air safetyBureaus of air safety

• Industry meetings & Industry meetings & conferencesconferences

• MilitaryMilitary

• Academic reportsAcademic reports

RAAF Review:2008RAAF Review:2008

• “…first-ever comprehensive and definitive attempt to document and encapsulate the problem of aircraft cabin air quality in one book.”

• ““....ground-breaking and seminal work.”

• “A notable and distressing element of the data is the widespread prevalence of denial of the existence of the problem, particularly among the aircraft operators and aviation regulators.”

ACARM – Key FactsACARM – Key Facts

• Flight safety is being compromised.Flight safety is being compromised.

• Passengers and crews suffering short and long term health effects.Passengers and crews suffering short and long term health effects.

• Data confirms FAA position of under reporting of events is Data confirms FAA position of under reporting of events is significantsignificant..

• Fume events are NOT rare.Fume events are NOT rare.

• Aviation ald OH&S regulations not being met.Aviation ald OH&S regulations not being met.

• Oil and hydraulic fluid contaminants are being found in various studies.Oil and hydraulic fluid contaminants are being found in various studies.

Chapter Breakdown….. 1/2Chapter Breakdown….. 1/2• ChaptersChapters

1.1. Understanding the Problem. Understanding the Problem.2.2. Flight Safety Aspects of Contaminated Air. Flight Safety Aspects of Contaminated Air.3.3. What is in Contaminated Air. What is in Contaminated Air.4.4. The Toxicology Debate. The Toxicology Debate.5.5. The Mislabelling of Engine Oils. The Mislabelling of Engine Oils.6.6. Effects On Crews and Passengers - Symptoms Seen and Effects On Crews and Passengers - Symptoms Seen and Reported.Reported.7.7. Medical Side - Doctors and Scientists. Medical Side - Doctors and Scientists.8.8. The Kolvar & other Australian Incidents - Findings of the The Kolvar & other Australian Incidents - Findings of the Australian ATSB.Australian ATSB.9.9. The Malmo BAe 146 Incident of 12 November 1999 and a The Malmo BAe 146 Incident of 12 November 1999 and a Swedish Perspective.Swedish Perspective.10.10. UK AAIB Report into the BAe 146 G-JEAK Incident of 05 Nov UK AAIB Report into the BAe 146 G-JEAK Incident of 05 Nov 2000.2000.11.11. UK AAIB Report into the Boeing 757 G-CPER Incident of 07 Sept UK AAIB Report into the Boeing 757 G-CPER Incident of 07 Sept 2003.2003.12.12. Frequency of Events and Under Reporting. Frequency of Events and Under Reporting.13.13. ASHRAE. ASHRAE.14.14. The ITF and the International Task Group on Aircraft Air Quality The ITF and the International Task Group on Aircraft Air Quality15.15. Regulations to Protect Us. Regulations to Protect Us.16.16. The Exposure Standard Debate. The Exposure Standard Debate.

Chapter Breakdown….. 2/2Chapter Breakdown….. 2/2• ChaptersChapters

17.17. What They Knew and What They Did: a BAe 146 Analysis. What They Knew and What They Did: a BAe 146 Analysis.18.18. The Inquiries. The Inquiries.19.19. The Public Conferences Including the 2005 BALPA The Public Conferences Including the 2005 BALPA Conference.Conference.20.20. The UK Civil Aviation Authority Report - Cabin Air Quality The UK Civil Aviation Authority Report - Cabin Air Quality 2004.2004.21.21. US Perspective. US Perspective.22.22. The Airline Industry Misinformation Campaign. The Airline Industry Misinformation Campaign.23.23. Occupational Health Research Consortium in Aviation Occupational Health Research Consortium in Aviation (OHRCA) Project.(OHRCA) Project.24.24. SAE. SAE.25.25. UK Committee On Toxicity (COT) UK Committee On Toxicity (COT)26.26. Filtration. Filtration.27.27. Canadian Perspective.. Canadian Perspective..28.28. Important Dates in the Chronology of the Contaminated Air Important Dates in the Chronology of the Contaminated Air Debate.Debate.29.29. Solutions and the Future. Solutions and the Future.

Appendices Breakdown 1/2Appendices Breakdown 1/2

• AppendicesAppendices

A01:A01: Typical Aircraft Air System. Typical Aircraft Air System.A02:A02: Incidents on the UK database as of 1 August Incidents on the UK database as of 1 August 2006.2006.A03:A03: Chemicals reported found in aircraft cabins Chemicals reported found in aircraft cabins and cockpits.and cockpits.A04:A04: MSDS extracts data of chemicals found in MSDS extracts data of chemicals found in commercial aircraft.commercial aircraft.A05:A05: BAe 146 Service Bulletins, Service Information BAe 146 Service Bulletins, Service Information Leaflets and Data confirming CAQ problem.Leaflets and Data confirming CAQ problem.A06:A06: BAe 146 Contaminated air events given to the BAe 146 Contaminated air events given to the Australian Senate by the FAAA.Australian Senate by the FAAA.

Appendices Breakdown 2/2Appendices Breakdown 2/2

• AppendicesAppendices

A07:A07: USA Contaminated air events as of 18 August USA Contaminated air events as of 18 August 1997 listed in a NIOSH HHE application.1997 listed in a NIOSH HHE application.A08:A08: AOPIS COT Committee report 'AOPISCOT024' AOPIS COT Committee report 'AOPISCOT024' dated 3 July 2006.dated 3 July 2006.A09:A09: ASRS data: 'Smoke/fire/odor related incidents ASRS data: 'Smoke/fire/odor related incidents involving ATR 42, B757 & BAe 146 aircraft.'involving ATR 42, B757 & BAe 146 aircraft.'A10:A10: Air monitoring research summary. Air monitoring research summary.A11:A11: AOPIS COT Committee report 'AOPISCOT025' AOPIS COT Committee report 'AOPISCOT025' dated 26 February 2007.dated 26 February 2007.A12:A12: AOPIS response to COT - TOX 2006/39 and AOPIS response to COT - TOX 2006/39 and TOX 2007/10 dated 16 March 2007.TOX 2007/10 dated 16 March 2007.

Chapter 2: Flight Safety Chapter 2: Flight Safety aspects of contaminated airaspects of contaminated air

• Flight Safety is definitely being Flight Safety is definitely being compromisedcompromised

• Global issueGlobal issue

• Impairment is occuring in flight: Cabin crew Impairment is occuring in flight: Cabin crew & Pilots& Pilots

• Regulations are not being metRegulations are not being met

• Airline industry is not treating contaminated Airline industry is not treating contaminated air adequately as a flight safety issue: Often air adequately as a flight safety issue: Often dismissing as an OH&S issuedismissing as an OH&S issue

Chapter 3: What is in Chapter 3: What is in Contaminated air? Appx 3,4,10Contaminated air? Appx 3,4,10• Extensive mixture of contaminantsExtensive mixture of contaminants• Hazardous substancesHazardous substances

– Organophosphate, TCP (antiwear additive) at 3% - (ortho Organophosphate, TCP (antiwear additive) at 3% - (ortho isomers >0.3% [Mobil 2000] - hazardous / toxic levels isomers >0.3% [Mobil 2000] - hazardous / toxic levels

– PAN, skin sensitizer (antioxidant) - 1% - Hazardous levelsPAN, skin sensitizer (antioxidant) - 1% - Hazardous levels– BNA – Cat 1 known & prohibited human bladder BNA – Cat 1 known & prohibited human bladder

carcinogencarcinogen• Synergistic mix of contaminantsSynergistic mix of contaminants• Adequate testing has not been doneAdequate testing has not been done• TCP is being found in aircraft swab samples, air monitoring TCP is being found in aircraft swab samples, air monitoring

& pilots blood & pilots blood

Where Has TCP been Where Has TCP been identified?identified?• TCPTCP found in found in crew blood testscrew blood tests and on crew clothing. and on crew clothing.• TCPTCP found in found in swab testsswab tests from the surface of the flight deck from the surface of the flight deck

& cabin walls and in cockpit roof top filters, HEPA filters. & cabin walls and in cockpit roof top filters, HEPA filters. (2005-2007)(2005-2007)– Australia, UK, USA, EuropeAustralia, UK, USA, Europe– B747,B777,B767,B757,B737,A330,BAe146,MD80,DCH8: B747,B777,B767,B757,B737,A330,BAe146,MD80,DCH8:

85% positive85% positive• TCPTCP found in found in aircraft ductingaircraft ducting. (CAA 2004). (CAA 2004)• TCPTCP found in found in air samplingair sampling by RAAF (1988, 2005) and by RAAF (1988, 2005) and

Honeywell (1997,2000), Qantaslink(1998)Honeywell (1997,2000), Qantaslink(1998)• Allied Signal 1997: Allied Signal 1997: TCPTCP detected 4 times greater than detected 4 times greater than

allowed (Australian Senate, 2007)allowed (Australian Senate, 2007)• TCP identified in Cranfield University DfT testing 2007TCP identified in Cranfield University DfT testing 2007• CO detected in flight on the BAe 146 in 83% of surveyed CO detected in flight on the BAe 146 in 83% of surveyed

flights. (ACARM 2007)flights. (ACARM 2007)

Contaminated air is Contaminated air is predominantly related to oil predominantly related to oil fumesfumes

• Rolls Royce 1990:Rolls Royce 1990: ‘‘The approach adopted some years The approach adopted some years ago by Rolls Royce was to recognize the fact that in the ago by Rolls Royce was to recognize the fact that in the majority of instances where cabin air contamination majority of instances where cabin air contamination was a problem, it was mostly associated with small was a problem, it was mostly associated with small leakages of synthetic lubricant from bearing seals etc.’leakages of synthetic lubricant from bearing seals etc.’

• ATSB:ATSB: ‘Failure of oil seals has been a common factor in Failure of oil seals has been a common factor in the majority of cabin fume incidents.’the majority of cabin fume incidents.’

• CASA:CASA: ‘All aircraft from time to time suffer fumes l aircraft from time to time suffer fumes within the aircraft… that is a feature of the basic design within the aircraft… that is a feature of the basic design of air-conditioning systems in aircraft, being bleed air of air-conditioning systems in aircraft, being bleed air from engines.’from engines.’

• CAA, Ansett, BAe…CAA, Ansett, BAe… ‘‘Oil leakage is primary cause of Oil leakage is primary cause of fumes.’fumes.’

Chapter 4: The toxicology Chapter 4: The toxicology debatedebate

• TCP : Neurotoxin , OPICN , Other Ortho TCP : Neurotoxin , OPICN , Other Ortho isomers: Increased toxicity known since isomers: Increased toxicity known since 19581958

• PAN: sensitizerPAN: sensitizer• Synergistic mixSynergistic mix• Inhalation toxicity testing for exposure to Inhalation toxicity testing for exposure to

heated jet engine oils has never been done.heated jet engine oils has never been done.• CASA- ‘Mobil Jet oil 2 – Known to be CASA- ‘Mobil Jet oil 2 – Known to be

harmful’ -2007harmful’ -2007

TCPTCP

• TCP for synthetic jet engine oils TCP for synthetic jet engine oils manufactured only in two plants in the manufactured only in two plants in the world and has a unique chemical signature.world and has a unique chemical signature.

• TCP has several isomers which fall into 3 TCP has several isomers which fall into 3 families: families: ORTHOORTHO, , METAMETA and and PARAPARA..

• ORTHO isomer neurotoxicity (TOCP) has ORTHO isomer neurotoxicity (TOCP) has been known since before the first car!been known since before the first car!

• META and PARA chronic toxicity (OPICN)now META and PARA chronic toxicity (OPICN)now emerging.emerging.

Ortho isomer Ortho isomer misunderstandingsmisunderstandings• ORTHOORTHO isomers divided into: isomers divided into: TOCPTOCP, , DOCPDOCP and and MOCPMOCP..• Focus has been on TOCP with UK House of Lords and CAA Focus has been on TOCP with UK House of Lords and CAA

reports of 2000 and 2004 failing to ever mention DOCP or reports of 2000 and 2004 failing to ever mention DOCP or MOCP.MOCP.

TOCP 0.006 ppmTOCP 0.006 ppm Toxicity factor x 1Toxicity factor x 1DOCP 6 ppmDOCP 6 ppm Toxicity factor x 5Toxicity factor x 5MOCPMOCP 3070 ppm 3070 ppm Toxicity factor Toxicity factor

x 10x 10• In ignoring DOCP and MOCP you underestimate the total In ignoring DOCP and MOCP you underestimate the total

ORTHO toxicity by a factor of ORTHO toxicity by a factor of 6.14 million6.14 million which has been which has been known since 1958 (Henschler)known since 1958 (Henschler)

• Must not refer to TOCP alone – (Henschler 1958)Must not refer to TOCP alone – (Henschler 1958)• Exposure standards used incorrectly (Mobil 1999).Exposure standards used incorrectly (Mobil 1999).

Chapter 5: Mislabelling of the Chapter 5: Mislabelling of the oilsoils

• MSDSs minimize riskMSDSs minimize risk

• Hazards are not adequately advised Hazards are not adequately advised on labels & MSDSon labels & MSDS

• Operators uncritcally accept MSDS Operators uncritcally accept MSDS findings & use this to minimize risk.findings & use this to minimize risk.

• Suitable risk assessments not being Suitable risk assessments not being donedone

Chapter 6: Effects on crews & Chapter 6: Effects on crews & passengers: Symptoms seen & passengers: Symptoms seen & ReportedReported

• Various surveys show similar pattern Various surveys show similar pattern of effectsof effects

• discrete occupational Syndrome: discrete occupational Syndrome: Aerotoxic SyndromeAerotoxic Syndrome

• Aerotoxic Syndrome (AS): Short & Aerotoxic Syndrome (AS): Short & long-term effectslong-term effects

• Following Aerotoxic slides: Courtesy of Prof C Winder UNSWFollowing Aerotoxic slides: Courtesy of Prof C Winder UNSW

Aerotoxic Aerotoxic SyndromeSyndrome

Sign or Symptom Number of cases/reports 89 248 53 112 7 50 21 106 Fainting/loss of consciousness/grey out 4% 4% 3/7 14% Respiratory distress, shortness of breath, respiration requiring oxygen 73% 2% 4/7 62% 26% 4% Irritation of eyes, nose and throat 7/7 32% 37% Eye irritation, eye pain 35% 74% 57% 24% 4/7 76% Sinus congestion 35% 54% 5% 2/7 Nose bleed 17% 1/7 4% Throat irritation, burning throat, gagging and coughing 2% 64% 57% 43% 2/7 76% Cough 69% 2/7 12% Difficulty in breathing, chest tightness 68% 3/7 62% Loss of voice 35% 1/7 Rashes, blisters (on uncovered body parts) 36% 4/7 48% 16% 8% Nausea, vomiting, gastrointestinal symptoms 26% 23% 15% 8% 6/7 58% 5% 15% Abdominal spasms/cramps/diarrhoea 26% 3/7 20% 5% 16% Blurred vision, loss of visual acuity 11% 13% 1% 4/7 50% 5% 4% Shaking/tremors/tingling 9% 3% 3/7 40% Numbness (fingers, lips, limbs), loss of sensation 8% 2% 4/7 10% 12% Trouble thinking or counting, word blindness, confusion, coordination problems

26% 39% 42% 6/7 58% 21% 22%

Memory loss, memory impairment, forgetfulness 42% 7/7 66% 26% Disorientation 26% 15% 4/7 16% 8% Dizziness/loss of balance 47% 6% 4/7 72% 16% 3% Light-headed, feeling faint or intoxicated 35% 54% 32% 7/7 21% 33% Chest pains 7% 81% 6% 2/7 22% Severe headache, head pressure 25% 52% 26% 7/7 86% 21% 33% Fatigue, exhaustion 7/7 62% 21% 30% Chemical sensitivity 32% 4/7 72% 26% 10% Immune system effects 21% 3% Behaviour modified, depression, irritability 26% 20% 60% 4/7 40% 27% Change in urine 3% 6% 4% Joint pain, muscle weakness, muscle cramps 29% 2/7 38% 5% 30%

Aerotoxic Aerotoxic SyndromeSyndromeFeatures:Features:

11 Associated with air crew exposure Associated with air crew exposure at altitude to atmospheric at altitude to atmospheric contaminants from engine oil or contaminants from engine oil or hydraulic fluidshydraulic fluids

22 Chronologically juxtaposed by the Chronologically juxtaposed by the development of a consistent development of a consistent symptomology of irritancy, toxicity, symptomology of irritancy, toxicity, neurotoxicity and chemical neurotoxicity and chemical sensitivitysensitivity

33 Obvious short term effects, but a Obvious short term effects, but a long term syndrome apparentlong term syndrome apparent

Aerotoxic Aerotoxic SyndromeSyndromeClusters of SymptomsClusters of Symptoms

Loss of consciousness/Inability to functionLoss of consciousness/Inability to function Symptoms of direct irritation to eye, Symptoms of direct irritation to eye,

airways or skinairways or skin Respiratory symptoms secondary to Respiratory symptoms secondary to

irritationirritation Skin symptoms secondary to irritationSkin symptoms secondary to irritation Gastrointestinal symptomsGastrointestinal symptoms Neurotoxic symptomsNeurotoxic symptoms Neurological/neuropsychological Neurological/neuropsychological

symptomssymptoms Nonspecific general symptoms such asNonspecific general symptoms such as

chronic fatigue, chemical sensitivitychronic fatigue, chemical sensitivity

2007 BAe 146 UK Pilot 2007 BAe 146 UK Pilot surveysurvey

• ResultsResults– 86% smelt contaminated air86% smelt contaminated air– 57% report short-long term AS effects57% report short-long term AS effects– 25% report medium – long-term AS 25% report medium – long-term AS

effectseffects– >8% appear to have lost medical >8% appear to have lost medical

certificate related to AScertificate related to AS

Chapter 7: Medical Side: Chapter 7: Medical Side: Doctors & ScientistsDoctors & Scientists• Short termShort termThese may include some or all of the effects listed:These may include some or all of the effects listed:

• Nausea, vomitingNausea, vomiting HeadachesHeadaches• DisorientationDisorientation Sore nose, eyes, throat Sore nose, eyes, throat • Skin RashesSkin Rashes Chest pains Chest pains• Tingling or numbness Breathing difficulty Tingling or numbness Breathing difficulty • Stupor Stupor Lethargy Lethargy• Tunnel vision Difficulty concentrating Tunnel vision Difficulty concentrating • Tremor Tremor Short term memory Short term memory

problemsproblems• VertigoVertigo Light headedness etc…. Light headedness etc….

Chapter 7: Medical Side: Chapter 7: Medical Side: Doctors & ScientistsDoctors & Scientists• Long-termLong-term effects include: effects include:

– Neurological effects: CNS,PNS: Jamal 1997, Jamal, Julu… 2002, 2005Neurological effects: CNS,PNS: Jamal 1997, Jamal, Julu… 2002, 2005– Autonomic nervous system effects: Jamal, Julu… 2002, 2005Autonomic nervous system effects: Jamal, Julu… 2002, 2005– Working memory / cognitive problems. (neuropsychological), Coxon Working memory / cognitive problems. (neuropsychological), Coxon

2002 / Mackenzie Ross 20062002 / Mackenzie Ross 2006– Chronic neurotoxicity (OPICN): Abou-Donia 2004, 2005Chronic neurotoxicity (OPICN): Abou-Donia 2004, 2005– Neuronal brain cell death: Abou-DoniaNeuronal brain cell death: Abou-Donia– Respiratory disorders: Burdon, Glanville 2005Respiratory disorders: Burdon, Glanville 2005– Immune system effects, fatigue, chemical sensitivity etc..Immune system effects, fatigue, chemical sensitivity etc..– Blood pathology disordersBlood pathology disorders– Strong occupational link: Cone 1983,1999 / Harper 2005Strong occupational link: Cone 1983,1999 / Harper 2005– Individual susceptibility: FurlongIndividual susceptibility: Furlong

• TCP Blood test: 6 of 10 TCP isomers are converted into the highly toxic TCP Blood test: 6 of 10 TCP isomers are converted into the highly toxic metabolite – psp: that inhibits the activity of a number of important metabolite – psp: that inhibits the activity of a number of important enzymes.enzymes.

• Gene expression: Gene expression effected by TCP at levels found in UK Gene expression: Gene expression effected by TCP at levels found in UK pilots’ blood.pilots’ blood.

Passenger on major US Passenger on major US AirlineAirline

European Pilot: European Pilot: Courtesy of Welcome Aboard Toxic AirlinesCourtesy of Welcome Aboard Toxic Airlines

Chapter 12: Frequency of Chapter 12: Frequency of eventsevents• Refer Appendix 2, 6, 7, 9Refer Appendix 2, 6, 7, 9• Less than 4% of events are reportedLess than 4% of events are reported

– COT- 1% of flights -COT- 1% of flights -– US – ~1 documented event per day in the US – underestimate US – ~1 documented event per day in the US – underestimate

over 18 months/ >50% involved diversions over 18 months/ >50% involved diversions (Murawaski/Supplee(2008))(Murawaski/Supplee(2008))

• Wide range of data available , often inconsistent or Wide range of data available , often inconsistent or incompleteincomplete

• Events are increasingEvents are increasing• Fume events are NOT rareFume events are NOT rare• FAA (2006): FAA (2006):

– ‘FAA’s growing concern over numerous reports of smoke/ fumes in cockpit/cabin’;

– FAA data analysis indicates numerous events not being reported.’• Source of fumes is predominantly oilSource of fumes is predominantly oil

Chapter 12 – Frequency of Chapter 12 – Frequency of eventsevents• Global issue: Global issue: Example of UK dataExample of UK data

– Number of events increasing over the years.Number of events increasing over the years.– Events occur on many aircraft types.Events occur on many aircraft types.– Less than 4% of events ever reported to airlines Less than 4% of events ever reported to airlines

of which only 48% of these events are reported to of which only 48% of these events are reported to the regulator.the regulator.

– 32% of reported CA events involved some 32% of reported CA events involved some degree of crew adverse impairment.degree of crew adverse impairment.

– 20% of CA events involve at least 1 pilot 20% of CA events involve at least 1 pilot impairment.impairment.

– 9% of CA events involved 2 pilot impairment9% of CA events involved 2 pilot impairment

Chapter 12 – Frequency of Chapter 12 – Frequency of eventsevents

– Oxygen used by 1 pilot only 4% of the Oxygen used by 1 pilot only 4% of the time and both pilots 12% of the time time and both pilots 12% of the time and usually temporarily only.and usually temporarily only.

– Engineering is often not finding source of the Engineering is often not finding source of the problem on first inspection.problem on first inspection.

– Crew errors are being made.Crew errors are being made.– Crews continue flight duty after exposure Crews continue flight duty after exposure

events.events.– Fume events often seen as normal or a Fume events often seen as normal or a

nuisance only.nuisance only.

Chapter 15: Regulations to Chapter 15: Regulations to protects crews & passengersprotects crews & passengers

• Aviation Regulations existAviation Regulations exist

• OH&S regulations existOH&S regulations exist

• REGULATIONS ARE NOT WORKING REGULATIONS ARE NOT WORKING OR BEING ENFORCED BY AIRLINE OR BEING ENFORCED BY AIRLINE INDUSTRY OR GOVERNMENT BODIESINDUSTRY OR GOVERNMENT BODIES

Airworthiness Ventilation Airworthiness Ventilation Regulation: 25.831Regulation: 25.831

• (a) …. the ventilation system must be (a) …. the ventilation system must be designed to provide a sufficient amount of designed to provide a sufficient amount of uncontaminated air to enable the uncontaminated air to enable the crewmembers to perform their duties without crewmembers to perform their duties without undue discomfort or fatigue and to provide undue discomfort or fatigue and to provide reasonable passenger comfort. reasonable passenger comfort. (b) Crew and passenger compartment air (b) Crew and passenger compartment air must be free from harmful or hazardous must be free from harmful or hazardous concentrations of gases or vapors.concentrations of gases or vapors.

Chapter 16: The exposure Chapter 16: The exposure standard debatestandard debate• An aircraft is a discrete occupational environmentAn aircraft is a discrete occupational environment• Exposure standards do NOT apply: Exposure standards do NOT apply: RAAF &RAAF &

• ‘It should be noted that that current safety standards differ from air quality levels that will provide a perceived acceptable level of customer and crew satisfaction. Contaminant levels may be well below recommended levels in currently accepted safety standards yet generate complaints, because they act in synergy with other contaminants or because some standards may be outdated and not have incorporated more recent scientific and medical evidence. In addition, extenuating circumstances on board aircraft (including humidity and cabin pressure) have not been studied to the extent that a new standard can be proposed - that incorporates these factors or identifies interactions between factors.’ - Honeywell 1997

• ‘OSHA standards (and others throughout the world) are not applicable to aircraft cabin air. Rather, they were designed by regulatory agencies for the industrial workplace and based on the assumption that the worker will be on the job 8 h per day,……... Can such terrestrial standards be applied to workers in the air (cockpit and cabin crew) and passengers with rationde-a rhetorical question to which the answer is, probably not.’ – R. Rayman, ASMa 2002

• …………………….

How long have we known How long have we known about these problems ?about these problems ?

• There is a very extensive database of There is a very extensive database of information showing how long this information showing how long this issue has been known. issue has been known. (ACARM 2007)(ACARM 2007)

•1953 -‘Concerns about toxicity of 1953 -‘Concerns about toxicity of various aviation products including various aviation products including oils & hydraulic fluids.’oils & hydraulic fluids.’AMA CAT (1953) Aviation Toxicology: an Introduction to the Subject and a Handbook of Data.

19771977: : Air National Guard Air National Guard C-130 HerculesC-130 Hercules

• ‘‘This report documents the incapacitation of This report documents the incapacitation of an aircraft navigator during flight. This an aircraft navigator during flight. This situation resulted from an inhalation situation resulted from an inhalation exposure to aerosolized or vaporized exposure to aerosolized or vaporized synthetic lubricating oil.’synthetic lubricating oil.’

• ‘‘Further investigation into the potential Further investigation into the potential hazards from inhalation of synthetic oil hazards from inhalation of synthetic oil fumes… is definitely warranted.’fumes… is definitely warranted.’

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.

Chapter 17: What they knew & Chapter 17: What they knew & what they did – BAe 146 case what they did – BAe 146 case studystudy

• See appx 5See appx 5

• Long history of oil fumesLong history of oil fumes

• Service Bulletins, service Information Service Bulletins, service Information leaflets, All Operator Messages, leaflets, All Operator Messages, Airworthiness Directives……Airworthiness Directives……

• There is NO secretThere is NO secret

Committee of Toxicity (COT)Committee of Toxicity (COT)

• COT review is seriously flawed – COT review is seriously flawed – – Fume events occuring in 1% of flights: While significant, Fume events occuring in 1% of flights: While significant,

was based on 3 UK airlines / primarily BA data : Ignored was based on 3 UK airlines / primarily BA data : Ignored real under-reporting & evidencereal under-reporting & evidence

– Ignored chronic health effects dataIgnored chronic health effects data– Causal link between fumes and effects denied: Data Causal link between fumes and effects denied: Data

ignoredignored– epidemiological research for any other acute or chronic epidemiological research for any other acute or chronic

health effects denied as available data ignored or health effects denied as available data ignored or significantly downplayedsignificantly downplayed

– Ignored TCP findings in aircraft, consequently advising Ignored TCP findings in aircraft, consequently advising against focus on TCPagainst focus on TCP

– ………………• Cranfield/DfT research based on COT studiesCranfield/DfT research based on COT studies

Chapter 29: Solutions 1/2Chapter 29: Solutions 1/2

• Contaminated air detection systems must be Contaminated air detection systems must be fitted. fitted.

• Bleed air filtration or bleed free supplies needed.Bleed air filtration or bleed free supplies needed.• Crew education to ensure 100% emergency Crew education to ensure 100% emergency

oxygen always used.oxygen always used.• Enforcement and education of the reporting Enforcement and education of the reporting

system.system.• Regulations such as 25.831 enforced. As well as Regulations such as 25.831 enforced. As well as

all aviation & OH&S regulations (HSE, NOHSC)all aviation & OH&S regulations (HSE, NOHSC)• Full scale epidemiological survey of crews.Full scale epidemiological survey of crews.• Less toxic oils and hydraulic fluids……… Less toxic oils and hydraulic fluids………

– NYCO - Tubonycoil 600NYCO - Tubonycoil 600

Chapter 29: Solutions 2/2Chapter 29: Solutions 2/2

• Address design issuesAddress design issues• TCP Biomarker blood test & gene toxicity studies - TCP Biomarker blood test & gene toxicity studies -

occuringoccuring• Inhalation studies of breathing oils & hydraulic fluidsInhalation studies of breathing oils & hydraulic fluids• B787B787• Regulators must become independent & regulateRegulators must become independent & regulate• Appropriate Inquiries & studies: US FAA funded Appropriate Inquiries & studies: US FAA funded

OHRCA;CASA 2008 EPAAQ, NIOH….OHRCA;CASA 2008 EPAAQ, NIOH….– OHRCA- OHRCA-

"Exposure to Aircraft Bleed Air Contaminants Amon"Exposure to Aircraft Bleed Air Contaminants Among Airline Workers: A Guide for Health Care Providersg Airline Workers: A Guide for Health Care Providers"". & Cabin crew survey. & Cabin crew survey

– CASA EPAAQ(2008)CASA EPAAQ(2008)• GCAQE – Funding Furlong blood testGCAQE – Funding Furlong blood test

Thank you for your Thank you for your attention.attention.

Do not ignore the Do not ignore the evidenceevidence

Aviation Contaminated Air Reference ManualAviation Contaminated Air Reference ManualISBN9780955567209 ISBN9780955567209

www.www.susanmichaelis.comsusanmichaelis.comsusan@susanmichaelis.comsusan@susanmichaelis.com