Culpability: aircraft cabin air contamination
By Peter Marosszeky, JP FRAeS MAOPA (USA)*
Passenger X was a domestic flight attendant flying on East West Airlines Ltd in 1992 between Sydney and Brisbane.
During the flight there was a noticeable toxic odour in the cabin which was later assessed to be synthetic engine oil fumes coming through the air conditioning system from the engine compressors and the auxiliary power unit.
Passenger X suffered an immediate serious breathing condition and has not been successfully treated since.
In commercial aviation, operators must follow clear guidelines and demonstrate compliance at all times to the Civil Aviation Safety Authority.
East West's fleet included several BAe 146-200 series aircraft used for domestic operations. The aircraft have four Garrett turbo prop engines that the manufacturer's guidelines require to be removed at about 2,000 flight hours to replace the engine's main compressor/turbine shaft seals. After 2,000 hours, the seals are no longer capable of effectively sealing bearing compartments to prevent hot oil from exiting and entering compressed air from the compressor and contaminating it.
That contaminated air entering the cabin's air conditioning and ventilation system.
Industry and scientific research found the fumes were toxic and carcinogenic and required special handling to avoid skin contact and inhalation. The BAe aircraft had a chronic history of cabin fumes that had been reported numerous times, but little was done due to various factors, primarily economic considerations.
The manufacturer's requirements were concise about appropriate actions to be taken by operators when the condition arose.
There were numerous cases of contaminated cabin air quality casualties, however they all lacked evidence to suggest culpability by aircraft operators.
Operators were quick to assign blame to the engine manufacturer for poor design and inadequate backup for corrective action. Considerable time and resources were expended until new lawyers were tasked with presenting Passenger X's case to court.
Due to the case's technical nature, it was difficult to find an expert witness who could research the material, afford the time and not fear for their career in the aviation industry.
Issue of culpability
From the records presented, the aircraft operator knowingly extended the in-service time on-wing of the engines to reduce operating costs. The expert needed to prove the operator was aware of the consequences of that action, resulting in incidents and unplanned engine changes when oil consumption and cabin air quality contamination became a major issue.
The operator's prescribed maintenance system and the manufacturer's specifications were not being complied with. However, to show evidence of non-compliance, the records had to show excessive oil consumption was determined during engine oil servicing after every landing, and that was not done.
The figures were deliberately not being recorded in the aircraft maintenance log. However, an in-depth search of the files found sufficient evidence to show the engines had excess oil consumption. The ‘smoking gun' was found in oil consumption records in only a few aircraft maintenance log pages when they were collated to cover many months.
It was obvious the entry of excessive oil consumption was not being highlighted or reported in accordance with procedures and regulations. If overconsumption was evident, the operator would be required to repair the engine. There was no immediate evidence to show that vital data recording was conducted by the certifying engineer, who would have to record the requirement not only to remove the engine but also to remove the pressurisation, ventilation and air conditioning ducting.
The judge found the lack of duty of care through evidence tendered to the court was sufficient to rule in Passenger X's favour and define the order of compensation. However, that is small comfort to a person who has suffered significantly and continues to do so because of the operator's deliberate lack of compliance.
This is an edited version of Peter's paper. To read the full paper, click here.
*Peter Marosszeky has 56 years of professional aviation background as an engineer, test engineer and airline executive. He has held a senior academic role at UNSW in aviation, been a guest lecturer at Sydney University and a visiting senior lecturer at the National University of Singapore.
Click here to read an October 2000 report by the Senate Rural and Regional Affairs and Transport References Committee: Air safety and cabin air quality in BAe 146 aircraft.