Transcript GCAQE Presentation - Airline Pilots Forum and Resource

IATA - CABIN HEALTH
CONFERENCE OCTOBER 2008
Captain Susan Michaelis
Aviation Contaminated Air
Reference Manual
An overview
Susan Michaelis • Former Australian Airline Pilot.(1986-1997) –Ill health
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retired
Winner 1987 CASA Sir Donald Anderson award - Best
academic merit
Commenced research 1997 (MSc 2002)
Head of Research - Global Cabin Air Quality Executive
(GCAQE).
PhD research student at the University of New South
Wales in Sydney, Australia.
Author of the Aviation Contaminated Air Reference
Manual (2007). (ACARM)
Aviation Contaminated Air
Reference Manual (ACARM)
ISBN:9780955567209
• Published in 2007.
• 1st time data has been collated.
• 844 pages of key information.
• Aviation industry data from 1953 – 2007
• Data is fully referenced / widely sourced
• Covers all main issues from incidents,
monitoring, health effects and flight safety
ACARM data taken from:
• Industry documents •
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wide variety
Published papers
Surveys
Union reports
Defect reports
Regulator reports
Medical reports
Legal / insurance reports
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Government data
Scientists & doctors
Aircrew & passengers
Media
Bureaus of air safety
Industry meetings &
conferences
Military
Academic reports
RAAF Review:2008
• “…first-ever comprehensive and definitive
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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 Facts
• Flight safety is being compromised.
• Passengers and crews suffering short and long term health
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effects.
Data confirms FAA position of under reporting of events is
significant.
Fume events are NOT rare.
Aviation ald OH&S regulations not being met.
Oil and hydraulic fluid contaminants are being found in
various studies.
Chapter Breakdown….. 1/2
• Chapters
1. Understanding the Problem.
2. Flight Safety Aspects of Contaminated Air.
3. What is in Contaminated Air.
4. The Toxicology Debate.
5. The Mislabelling of Engine Oils.
6. Effects On Crews and Passengers - Symptoms Seen and Reported.
7. Medical Side - Doctors and Scientists.
8. The Kolvar & other Australian Incidents - Findings of the Australian ATSB.
9. The Malmo BAe 146 Incident of 12 November 1999 and a Swedish
Perspective.
10. UK AAIB Report into the BAe 146 G-JEAK Incident of 05 Nov 2000.
11. UK AAIB Report into the Boeing 757 G-CPER Incident of 07 Sept 2003.
12. Frequency of Events and Under Reporting.
13. ASHRAE.
14. The ITF and the International Task Group on Aircraft Air Quality
15. Regulations to Protect Us.
16. The Exposure Standard Debate.
Chapter Breakdown….. 2/2
• Chapters
17. What They Knew and What They Did: a BAe 146 Analysis.
18. The Inquiries.
19. The Public Conferences Including the 2005 BALPA Conference.
20. The UK Civil Aviation Authority Report - Cabin Air Quality 2004.
21. US Perspective.
22. The Airline Industry Misinformation Campaign.
23. Occupational Health Research Consortium in Aviation (OHRCA)
Project.
24. SAE.
25. UK Committee On Toxicity (COT)
26. Filtration.
27. Canadian Perspective..
28. Important Dates in the Chronology of the Contaminated Air
Debate.
29. Solutions and the Future.
Appendices Breakdown 1/2
• Appendices
A01: Typical Aircraft Air System.
A02: Incidents on the UK database as of 1 August 2006.
A03: Chemicals reported found in aircraft cabins and
cockpits.
A04: MSDS extracts data of chemicals found in
commercial aircraft.
A05: BAe 146 Service Bulletins, Service Information
Leaflets and Data confirming CAQ problem.
A06: BAe 146 Contaminated air events given to the
Australian Senate by the FAAA.
Appendices Breakdown 2/2
• Appendices
A07: USA Contaminated air events as of 18 August 1997
listed in a NIOSH HHE application.
A08: AOPIS COT Committee report 'AOPISCOT024' dated
3 July 2006.
A09: ASRS data: 'Smoke/fire/odor related incidents
involving ATR 42, B757 & BAe 146 aircraft.'
A10: Air monitoring research summary.
A11: AOPIS COT Committee report 'AOPISCOT025' dated
26 February 2007.
A12: AOPIS response to COT - TOX 2006/39 and TOX
2007/10 dated 16 March 2007.
Chapter 2: Flight Safety aspects of
contaminated air
• Flight Safety is definitely being compromised
• Global issue
• Impairment is occuring in flight: Cabin crew &
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Pilots
Regulations are not being met
Airline industry is not treating contaminated air
adequately as a flight safety issue: Often
dismissing as an OH&S issue
Chapter 3: What is in Contaminated
air? Appx 3,4,10
• Extensive mixture of contaminants
• Hazardous substances
– 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 mix of contaminants
• Adequate testing has not been done
• TCP is being found in aircraft swab samples, air monitoring & pilots
blood
Where Has TCP been identified?
• TCP found in crew blood tests and on crew clothing.
• TCP found in swab tests from the surface of the flight deck & cabin
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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), Qantaslink(1998)
Allied Signal 1997: TCP detected 4 times greater than allowed
(Australian Senate, 2007)
TCP identified in Cranfield University DfT testing 2007
CO detected in flight on the BAe 146 in 83% of surveyed flights.
(ACARM 2007)
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.’
• ATSB: ‘Failure of oil seals has been a common factor in the
majority of cabin fume incidents.’
• CASA: ‘All aircraft from time to time suffer fumes within the
aircraft… that is a feature of the basic design of air-conditioning
systems in aircraft, being bleed air from engines.’
• CAA, Ansett, BAe… ‘Oil leakage is primary cause of fumes.’
Chapter 4: The toxicology debate
• TCP : Neurotoxin , OPICN , Other Ortho isomers:
Increased toxicity known since 1958
• PAN: sensitizer
• Synergistic mix
• Inhalation toxicity testing for exposure to heated
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jet engine oils has never been done.
CASA- ‘Mobil Jet oil 2 – Known to be harmful’ 2007
TCP
• TCP for synthetic jet engine oils manufactured
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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 (TOCP) has been
known since before the first car!
META and PARA chronic toxicity (OPICN)now
emerging.
Ortho isomer misunderstandings
• ORTHO isomers divided into: TOCP, DOCP and MOCP.
• Focus has been on TOCP with UK House of Lords and
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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 (Henschler)
Must not refer to TOCP alone – (Henschler 1958)
Exposure standards used incorrectly (Mobil 1999).
Chapter 5: Mislabelling of the oils
• MSDSs minimize risk
• Hazards are not adequately advised on
labels & MSDS
• Operators uncritcally accept MSDS findings
& use this to minimize risk.
• Suitable risk assessments not being done
Chapter 6: Effects on crews &
passengers: Symptoms seen &
Reported
• Various surveys show similar pattern of
effects
• discrete occupational Syndrome: Aerotoxic
Syndrome
• Aerotoxic Syndrome (AS): Short & longterm effects
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Following Aerotoxic slides: Courtesy of Prof C Winder UNSW
Aerotoxic Syndrome
Sign or Symptom
Number of cases/ reports
Fainting/loss of consciousness/grey out
Respiratory distress, shortness of breath, respiration requiring oxygen
Irritation of eyes, nose and throat
Eye irritation, eye pain
Sinus congestion
Nose bleed
Throat irritation, burning throat, gagging and coughing
Cough
Difficulty in breathing, chest tightness
Loss of voice
Rashes, blisters (on uncovered body parts)
Nausea, vomiting, gastrointestinal symptoms
Abdominal spasms/cramps/diarrhoea
Blurred vision, loss of visual acuity
Shaking/tremors/tingling
Numbness (fingers, lips, limbs), loss of sensation
Trouble thinking or counting, word blindness, confusion, coordination
problems
Memory loss, memory impairment, forgetfulness
Disorientation
Dizziness/loss of balance
Light-headed, feeling faint or intoxicated
Chest pains
Severe headache, head pressure
Fatigue, exhaustion
Chemical sensitivity
Immune system effects
Behaviour modified, depression, irritability
Change in urine
Joint pain, muscle weakness, muscle cramps
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4%
35%
35%
2%
26%
26%
11%
9%
26%
248
4%
73%
53
74%
54%
17%
64%
69%
68%
35%
57%
23%
2%
24%
5%
57%
43%
36%
15%
8%
8%
1%
3%
2%
13%
39%
112
42%
42%
26%
47%
35%
7%
25%
15%
6%
32%
6%
26%
54%
81%
52%
32%
26%
20%
3%
29%
60%
6%
7
3/7
4/7
7/7
4/7
2/7
1/7
2/7
2/7
3/7
1/7
4/7
6/7
3/7
4/7
3/7
4/7
50
14%
62%
21
106
26%
32%
4%
37%
16%
5%
5%
5%
8%
15%
16%
4%
10%
12%
6/7
58%
21%
22%
7/7
4/7
4/7
7/7
2/7
7/7
7/7
4/7
66%
26%
16%
16%
21%
8%
3%
33%
4/7
40%
4%
38%
2/7
76%
4%
76%
12%
62%
48%
58%
20%
50%
40%
72%
22%
86%
62%
72%
21%
21%
26%
21%
33%
30%
10%
3%
27%
5%
30%
Aerotoxic Syndrome
Features:
1 Associated with air crew exposure at
altitude to atmospheric contaminants
from engine oil or hydraulic fluids
2 Chronologically juxtaposed by the
development of a consistent
symptomology of irritancy, toxicity,
neurotoxicity and chemical sensitivity
3 Obvious short term effects, but a long
term syndrome apparent
Aerotoxic Syndrome
Clusters of Symptoms
 Loss of consciousness/Inability to function
 Symptoms of direct irritation to eye, airways
or skin
 Respiratory symptoms secondary to
irritation
 Skin symptoms secondary to irritation
 Gastrointestinal symptoms
 Neurotoxic symptoms
 Neurological/neuropsychological symptoms
 Nonspecific general symptoms such as
chronic fatigue, chemical sensitivity
2007 BAe 146 UK Pilot survey
• Results
– 86% smelt contaminated air
– 57% report short-long term AS effects
– 25% report medium – long-term AS effects
– >8% appear to have lost medical certificate
related to AS
Chapter 7: Medical Side: Doctors &
Scientists
• Short term
These may include some or all of the effects listed:
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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….
Chapter 7: Medical Side: Doctors &
Scientists
• Long-term effects include:
– 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, 2005
– Neuronal brain cell death: Abou-Donia
– Respiratory disorders: Burdon, Glanville 2005
– Immune system effects, fatigue, chemical sensitivity etc..
– Blood pathology disorders
– Strong occupational link: Cone 1983,1999 / Harper 2005
– Individual susceptibility: Furlong
• 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 enzymes.
• Gene expression: Gene expression effected by TCP at levels found in UK pilots’ blood.
Passenger on major US Airline
European Pilot:
Courtesy of Welcome Aboard Toxic Airlines
Chapter 12: Frequency of events
• Refer Appendix 2, 6, 7, 9
• Less than 4% of events are reported
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– COT- 1% of flights – US – ~1 documented event per day in the US – underestimate over 18
months/ >50% involved diversions (Murawaski/Supplee(2008))
Wide range of data available , often inconsistent or incomplete
Events are increasing
Fume events are NOT rare
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 oil
Chapter 12 – Frequency of events
• Global issue: Example of UK data
– Number of events increasing over the years.
– Events occur on many aircraft types.
– Less than 4% of events ever reported to airlines of
which only 48% of these events are reported to the
regulator.
– 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
Chapter 12 – Frequency of events
– Oxygen used by 1 pilot only 4% of the time
and both pilots 12% of the time and usually
temporarily only.
– Engineering is often not finding source of the
problem on first inspection.
– Crew errors are being made.
– Crews continue flight duty after exposure events.
– Fume events often seen as normal or a nuisance
only.
Chapter 15: Regulations to protects
crews & passengers
• Aviation Regulations exist
• OH&S regulations exist
• REGULATIONS ARE NOT WORKING OR
BEING ENFORCED BY AIRLINE INDUSTRY
OR GOVERNMENT BODIES
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.
Chapter 16: The exposure standard
debate
• An aircraft is a discrete occupational environment
• Exposure standards do NOT apply: 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
about these problems ?
• There is a very extensive database of
information showing how long this issue
has been known. (ACARM 2007)
• 1953 -‘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.’
• ‘Further investigation into the potential hazards
from inhalation of synthetic oil 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 &
what they did – BAe 146 case
study
• See appx 5
• Long history of oil fumes
• Service Bulletins, service Information
leaflets, All Operator Messages,
Airworthiness Directives……
• There is NO secret
Committee of Toxicity (COT)
• COT review is seriously flawed –
– Fume events occuring in 1% of flights: While significant, was
based on 3 UK airlines / primarily BA data : Ignored real underreporting & evidence
– Ignored chronic health effects data
– Causal link between fumes and effects denied: Data ignored
– epidemiological research for any other acute or chronic health
effects denied as available data ignored or significantly
downplayed
– Ignored TCP findings in aircraft, consequently advising against
focus on TCP
– ………
• Cranfield/DfT research based on COT studies
Chapter 29: Solutions 1/2
• Contaminated air detection systems must be fitted.
• Bleed air filtration or bleed free supplies needed.
• Crew education to ensure 100% emergency oxygen
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always used.
Enforcement and education of the reporting system.
Regulations such as 25.831 enforced. As well as all
aviation & OH&S regulations (HSE, NOHSC)
Full scale epidemiological survey of crews.
Less toxic oils and hydraulic fluids………
– NYCO - Tubonycoil 600
Chapter 29: Solutions 2/2
• Address design issues
• TCP Biomarker blood test & gene toxicity studies •
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occuring
Inhalation studies of breathing oils & hydraulic fluids
B787
Regulators must become independent & regulate
Appropriate Inquiries & studies: US FAA funded
OHRCA;CASA 2008 EPAAQ, NIOH….
– OHRCA- "Exposure to Aircraft Bleed Air Contaminants
Among Airline Workers: A Guide for Health Care
Providers". & Cabin crew survey
– CASA EPAAQ(2008)
GCAQE – Funding Furlong blood test
Thank you for your
attention.
Do not ignore the evidence
Aviation Contaminated Air Reference Manual
ISBN9780955567209
www.susanmichaelis.com
[email protected]