Cockpit Flight Reports of pilots after fume events
We currently know of four such retrospective "Flight Report Cockpit" (FRC) descriptions. Most incidents remain unknown to the public. We have documented why this is the case here: "Incidents": incidents that usually do not appear in the official statistics. Following examples are also listed: how many fume events can be researched afterwards, how many of them are registered with the AAIB, how many of them then appear in the statistics of the Federal Aviation Authority and what is in the end still noticed by the EASA. It works like a funnel: only very little of what comes in at the top appears at the other end.
There are also no standardised reporting channels. And the airlines are "not amused" about such reports. In fact, the ducts from the engines to the cabin and/or the air conditioning system ("packs") with its various pipe systems would have to be replaced.
That takes time. Up to 30 hours. A period during which the aircraft does not earn any money and upsets the entire flight schedule. So it is no wonder that the technical logbooks are also changed (i.e. manipulated) from time to time; for example, as happened on a Lufthansa flight to Dubrovnik on 16th September 2016 (more on this see the link above). But it is even rarer that such cases become known.
The four "FRC" are listed in chronological order below. We begin with the year 2010. Each FRC is dated and mentions the airline and aircraft type, departure and destination airport and whether the BFU (Federal Bureau of Aircraft Accident Investigation) has recorded and investigated the incident. In most cases it does not. Such incidents are generally not counted as a "serious incident". In other words: the AAIB regards fume events as a normal part of everyday life.
We do not mention the involved pilots’ names, or have anonymized them.
Cockpit Flight Report No. 1: December 19th, 2010: Vienna > Airport Cologne-Bonn
Airline Germanwings (Lufthansa), Airbus A 319-132 (D-AGWK)
It is probably one of the most dramatic incidents that have (so far) become known. But we can only guess, we don't know exactly - most incidents are not reported and therefore not known (see chapter "Incidents": Incidents that do not usually appear in official statistics).
But we know from the two flight reports of the captain and the co-pilot ("FO") what happened during this flight in the few minutes in the cockpit.
Here first the Captain's report, which he wrote down eleven days later on New Year's Eve 2010. Probably because he wanted to review the process again.
Here is the captain is speaking:
"I like to quote an ‚aviatior’s wisdom’: Aviation consists of waiting for hours followed by moments of startling surprises.
One day I learned how true this saying could be.
The weather forecast for that day was not good. Heavy snow was predicted from midday onward for Cologne. Our rotation was to take us to Vienna first, then to Milano. Check-in was at 13:25 LT – preparations for the flight were normal.
I knew the co-pilot from having met him two days earlier on another rotation with heavy winter flight operations. I knew that he had had his final online-check several months ago and remembered him working very carefully and conscienciously. The mood was good and we were looking forward to what the day might bring. First snow flakes started falling during the walk around and while waiting on parking position following de-icing, it increased. Our taxi to 14L was short, and after only a few minutes off-blocks we were able to take-off. The flight to Vienna was without issues and in Vienna we even encountered a little sunshine and excellent flight weather.
After on-blocks in Vienna we got the first bad slot for the return flight since it had started snowing heavily in Cologne, and no improvement was expected. After about 3 hours of waiting, the conditions in Cologne seemed to improve and the re-opening of the airport a possibility.
We received a slot for about 50 minutes later, so boarding commenced immediately. Nevertheless, time was becoming short and we worried that we might lose the slot.
Operations was able to extend the slot another 10 minutes since we had to de-ice before take-off. Time pressure increased. Still, we were ‚released’ about 20 minutes before the slot time ended. We taxied to the de-icing position and were the first in line, as we seemed to be the only ones who had to de-ice. The person de-icing was not aware about the time pressure and we did not inform him about it, in order to not create stress. The de-icing procedure went unusually fast, nevertheless. Even under time pressure the cockpit crew team-work functioned well. My suggestion to move the take-off checklist forward to save time, was intercepted with the reference to the outstanding after-start checklist, so we both resumed back to our normal sequences. Taxi to 16 was short and we were able to depart Vienna within the very last minute of our slot.
The flight was uneventful. I was pilot flying on this leg. At this time we already knew that due to our delay of 4 hours, we wouldn’t be able to fly to Milano– due to that we were looking forward to our evening off. I ate my ‚Hot-Meal’ and during cruise we talked animatedly about the importance of sticking to procedures under time pressure. Descent to Cologne was practically a ‚continous descent’. Work atmosphere was professional and concentrated. We received radar vector for ILS on 14 L.
Banking to base leg I noticed for the first time this strange smell. My first thought was that it definitely smelled burned and electric. The smell was so strong, that I asked my co-pilot, who confirmed my impression. I asked the purser, who did not confirm smells in the cabin, also none in the rear of the aircraft, which he checked with the colleagues there. At this moment a thought went through my head, wondering if it would not be best to don the oxygen mask. I didn’t follow up on this thought since the smell had discipated by now and we also received intercept turn and clearance for ILS 14L.
In retrospect I am not even sure if the smell had really disappeared, or if I couldn’t smell it because our noses had already gotten used to it.
During localizer intercept the co-pilot suddenly announced that he felt ‚incredibly sick’ and that he had to don his mask. The tone of his voice gave me more of a fright than his actual words, as there was noticable alarm and shock to be heard. Before I could think or even answer, I suddenly felt strong tingling in my hands and feet. At the same time I truly felt that my senses were dwindling. My vision suddenly reduced and I noticed strong dizziness beginning, at which time fear, that I was losing control over my body and my actions before being able to do anything about it, gripped me. My reflexes made me reach for the mask as we practise often during simulator training.
Then everything started happening at once. We were still on director and I told the FO in a few short words that he should tell them that we had to change to Tower frequency. He did this and just before he called that in, I ordered him to set off a mayday call. I can only remember in bits his use of wording, but he added ‚mayday’ and that we had a ‚strong smell’ in the cockpit. At this time I noticed that the glide scope was already running and put flaps in position one, myself. I noticed quickly how restricted communication was under the mask, especially in such a highly dynamic situation.
Tower responded immediately and instructed an easyJet to do a go-around. Speed reduced very slowly and we were still over 200kt, so we were unable to switch to flaps postion 2. Approximately at this stage I must have switched off the AP, but I cannot remember details. I ordered gear-down and pulled the speed-brake. Still the speed seemed to reduce painfully slow. Communication was for me more difficult than it was in the simulator, since I felt that the ‚noise’ of my own breathing in the interphone was incredibily distracting and stressful. Capacity to turn the INT switch on and off all the time eluded me, since I was flying manually. Due to this there were constant communication problems between the FO and myself, since he sometimes could not hear me. At some stage I switched the transmission channel on the ACP to INT in order to work with the PTT on the side stick whenever I wanted to say something on the interphone.
During the entire landing phase I felt physically very ill. My impression was such, that while flying manually with the flight director, I was at the absolute upper limit of my possible abilites. Why this was the case I could not understand, but it made me feel afraid and I contemplated auto-landing, but dismissed the thought again since I was unable to think clearly. Too many things to think about – I thought – and, to recall all of that, I was not able anymore. The only thing that still worked was my ‚fallback’ to manual flying.
The final configuration was then fairly quickly established but the speed took, for my feeling, ages to decrease. I told my FO that I would disable the 1000ft gate if the speed wouldn’t be within limits by then, since I didn’t feel physically or mentally able to do a go-around. This realisation shocked me, as a go-around is a standard manouevre which is usually a purely, practised, reflex controlled, action.
But in this situation I felt unable to do so.
Nevertheless, the team still functioned despite the restricted communcation and performance capacities. For example, the FO reminded me of the landing check list which I would have completely omitted. At minimum our communication was disturbed due to the fact that I had forgotten to press PTT before my first Continue-Call.
During short final I noticed a reducing speed trend which I counter-acted with increased power thrust. I think I increased short term up to 65% N1. Speed remained the same anyway and I remember asking myself what exactly was happening here. For a moment I had the impression that I understand hardly anything of what was happening. I recognised the many blue lights, saw the runway and my goal was to land no matter how.
Touch down was in my opinion, normal. Auto-brake was on medium and seemed to work. I used my feet to brake only on the last meters. My aim was A3 turn-off, which I told the FO. But, we slipped so heavily on the last bit, that I was worried not to make it. Still we managed to to decrease speed to the point of being able to take A3, and for a short moment relief flooded me that we had reached ground safely. This was quickly surpressed and replaced by an empty feeling and a big question mark. This is where my concept ended.
When ‚chair-flying’, I had often acted through situations like i.e. a bomb threat, and had many concepts ready at hand what to do and what to say in announcements. But, in this situation it had ended when I landed. I began constructing a new concept. To stop on the spot and evacuate seemed over the top since the situation in the cockpit was in hand and no further danger seemed imminent. My goal was to get an apron position with stairs and to disembark the passengers as normal as possible. This brain storming went fairly fast and without an increase in the thought process in an epic manner. I am not sure anymore, I seem to remember that I mentioned to the FO that an apron position seemed most sensible.
Tower told us that the fire-engines were available and ready to speak with me, but did not confirm. At this moment I remembered that I had just refreshed my memory concerning the hand-out smoke/ fire refreshers a few days ago, and was able to recall frequency 123,1. I told the FO that I would communicate with the fire-brigade and he should communicate with the Tower. I do not remember though if I handed over controls.
First I explained the basic situation to the fire-brigade and told them, that at this time, there was no visible smoke and no fire in the cockpit and that the situation in the cabin was normal. With half an ear I heard that Tower told us we could park wherever we wanted to. Since we had received C07 via company frequency during descent , we decided to take that one since with that the most important request, to park on apron, was met.
Tower told the fire-brigade, who then asked me to taxi to A07, as that position was far away from buildings. That seemed sensible to me, so my FO confirmed that info to Tower.
We continued taxi on TWY A direction terminal. Following communication with the fire brigade and a decision regarding parking position had been made, I was finally able to speak with the cabin crew, since my biggest worry in the back of my mind since landing had been the well being of my cabin crew and passengers. I wanted to know if the situation was still normal, but I did assume it was, since I would otherwise have had feedback. Nevertheless, I imagined they would be worried seeing the large presence of fire engines was obvious. I wanted to reassure them as quickly as I could. Making an announcement from under the respirator mask was not an option since doing so would contradict the inconspicious situation and would have caused the opposite. I prepared myself and rang the purser. I told him in short what had happened, but also, that the situation was under control and that we would taxi to an apron position. I also said, that I would then immediatley remove the mask after opening the window and then make an announcement.
After setting parking brakes we realised that the APU was not running. While that was rectified we opened both windows. It felt like the APU took ages to start running. I couldn’t wait that long to make an announcement, since latest when arriving at parking position and with the many emergency blue lights illuminating the area , even the last passenger had to have noticed something was wrong. Due to the open windows and the still running engines the noise was infernal, so I tried to cover the microphone handset with my left hand while making an announcement.
I told the passengers that the fire-brigade was there as a precautionary measure after having some unusual smells in the cockpit during descent, and that they would now come on-board to ensure themselves that there was no further danger imminent and that all passengers could disembark therafter. Since my adrenalin levels were still fairly high I remembered the trick in such a situation was to speak so slowly that it seems unnormal, in order to avoid speaking too fast. The purser’s feedback later said that the announcement came across well and was understandable. When I finished the announcement I switched the engines off. The FO reminded me of the parking check list. I then closed the window - not really intentionally but automatically, as cold air was coming in and water was dripping , but instantly an urgent request from the right came to re-open the window. I looked across to my FO being aware of him for the first time in a while. He once again said that he felt really, really ill and I got a fright at how bad he looked. I immediately opened the window again and then saw my colleague who was now hanging with his entire upper body out of the window. My first thought was that he might be vomiting, but he was only desperately trying to get some fresh air, as he told me later.
The purser announced ‚all doors in park’, and the seat-belt signs were turned off, after which the fire-brigade leader entered the cockpit. We spoke and I said, that in our opinion there was no further danger to be expected in cockpit or cabin. I pointed out how bad the FO’s condition was.
He called the emergency team who immediately removed the FO to the ambulance. I remember that he had managed to get up from his seat by himself, but then had to be supported. I was asked how I was , but I felt that I could remain until all passengers had left the aircraft.
While talking with the team leader regarding further actions, I noticed how my whole body began to shake, which worries me to this day, as I do not know such symptoms. To this day I do not know if the reason for this was pathological, or the aftermath from the stress. Luckily the phenomena stopped a few seconds later.
I asked the team leader if the fire-brigade could retreat a bit in order for the passenger busses to approach and to begin disembarkation, and communicated this also to the passengers.
I stood in the cockpit entrance during disembarkation to see how the passengers’ mood was, and was happy to note that they were friendly and calm.
As soon as the last one had left, many different people approached me and everybody wanted to know something. First, I wanted to know how my FO was faring. I had noticed that the ambulances were still standing close by and assumed that was a good sign. I was assured that his condition was acceptable and that the ambulances were waiting to take me to hospital to be examined. I also remembered that the purser mentioned that the smell was still noticable in front of the cockpit door. At the time when this comment was made both cockpit windows had already been open for 15 minutes.
I then spoke with the cabin crew and quickly noticed that they were psychologically ok. I described what had happened and asked how they experienced the situation. As I had thought, for the two in the back galley the landing was normal and they did not feel to have been in danger at any time. Also the purser made a stable impression, so I decided after pointing out the possible and available help by the CISM team, to send the cabin crew to their well earned evening
Following this I spoke with maintenance and made a WO entry. To my astonishment the MCC worker present seemed at that point in time already sure that it was de – icing fluid that had been the reason for the incident.
I was being harrassed to fill in a form right away by the fire-brigade operations manager who pushed it in to my hand. I asked if I could do it later, which he denied. So I filled in the §5 LuftVO incident report which, looking back, I should have declined to do since I was still feeling physically unwell. I should have better communicated how unwell I felt and should have only filled in my personal details.
After finishing the paper work and handing the aircraft over to maintenance I collected my things and the FO’s, and went to the ambulance. There, I saw my FO who was still looking very ill, lying in a reclining chair covered with a blanket, and an oxygen tube in his nose. An image which shocked me.
The paramedics immediately put an O2 tube on me as well and measured my O2 levels. I don’t remember the exact value, but remember that it was, according to the paramedics, very bad and clearly under 80%. Normal values are, to my knowledge, around 95-98%.
I had to answer a few questions before the trip to the hospital in Porz could begin.
On the way I made a telephone call to IOCC and heard that Mr Knitter wanted to know what the passengers had been told. I also called Mr Dunz to inform him about the occurrences.
The drive to Porz took much longer than it usually would due to the extrem wintery and difficult weather conditions on that evening.
What I clearly remember is the fact, that I continously began to feel better which was due to the O2 and the slowly improving O2 levels, as I was told by the paramedics. I had previously read about this, but now I experienced myself that I had not noticed before how bad I had actually felt. Only due to the obvious improvements I was able to realise how badly impaired I had been. I had the impression to have clear thoughts for the first time in about an hour. I now realised why I had had such difficulty with the decision making during descent concerning a seemingly simple thought process regarding the preparation for an auto-land or a go-around.
Following about 2 hours of examinations at the hospital, we were released and we drove by taxi to the airport. Because we felt we needed to discuss the happenings of the past hours, we held an intense debriefing.
All in all this incident showed me how quickly the border-line between normal and not normal operations can be crossed. I would have never thought that one could get in to a situation during which loss of controls could happen so fast. Theoretically I knew about it , but what it means in reality was shown clearly in this case.
Especially that one can also lose control within seconds on lower height levels shows how important it is never to let one’s attention diminish too much. It is very important to stress here that it is imperative to don the oxygen mask, even at the smallest suspicion of toxic fumes, wherever they might be originating from, and they don’t even need to smell strong, to incapacitate the pilots. I can’t imagine the scenario that could have happened if we had hesitated a second longer to don the masks. A pilot-less aircraft with 149 human beings onboard, drifting without configuration along the ILS - everyone can imagine the possible ending.
As I heard, the aircraft was back online the next day, and it was said that the reason given by maintenance was de-icing fluid in the air-conditioning.
I am fully aware that as a pilot my technical knowledge is less compared to a technician’s. But I do have 12 years of flying and operational experience, 7 of which on Airbus. I have had experiences with burned de-icing fluids in the air-conditioning, also in high concentrations with strong smoke development in the cabin. That’s why I find it hard to accept this diagnosis. I am also aware of the fact that experiences from other incidents with contaminated cabin air have shown that the reason that nothing could be detected afterwards was due to the volatile nature of the substances. But the intense smell that I detected and the physical reactions I felt, have definitely no similarity to that after burned de-icing fluids.
Perhaps it was luck that two days earlier I had prepared the smoke/ fire refresher and my FO, as he told me later, had just undergone his simulator refresher. It certainly showed me the imporance of constantly ‚refreshing’ oneself. Biannual simulator training is conforming to law and regulations, but can never suffice to prepare for the amount of failure possibilities one can be confronted with just before the end of a day.
I think it cannot be taken for granted every day, that we can get in the car after work and drive home. The fact that we sit in a thin aluminium hull, filled to the rim with fuel and human beings, travelling across a space unfit for living and close to the speed of sound clearly shows, that this job, as non-dangerous we seem to think it is, has it’s own risks. To keep these riks at a minimum is my duty as a captain.
The fact that nothing serious has happened for years, misleads to thinking that it is self evident and that the only relevant thing is, is to take care of daily operations. That preparations for the unexpected and extremely rare occasions can quickly determine between ‚good outcome’ and ‚bad outcome’, is something one has to be aware of over and over again.
To counteract such complacancy each one of us probably needs from time to time some provocation for thought. For me this incident was one.
My personal understanding of my duty as a captain has always been that I receive the smaller part of my salary for those sunny days flying an aircraft to Palma and back again.
The larger part is to be prepared for those rare occasions when it is necessary to be able to do the right thing. The biggest investment to be prepared, is time. And the time in our tight duty rosters is the most precious thing we have. But we do have more of it than we sometimes think. We just don’t use it. Often, a long flight phase goes unused and even boredom sets in. If one would use only part of such phases to discuss a smoke/fire procedure in full, one would use time wisely and make another step toward being prepared for such an uexpected incident.
I try to do this as often as possible and will probably do even more so in the future, even though I probably will, like most of us, lose the battle against idleness at times. Still, I am glad I was prepared. As unlikely as it might seem, the day can arrive when it can happen - as I had to experience myself.
The co-pilot's ("FO" / "Flight Officer") flight report reads much more dramatically and was not written in such a contemplative and retrospective perspective as the captain’s.
Explanation: "CM1" stands for "crew member 1" meaning the captain. Although it is quite unusual for two pilots to fly together so soon forming a crew, this was probably a decisive advantage this time: they trusted each other.
Normally, the crews in the cockpit and the cabin are reassembled for each flight. This is to prevent routine and/or negligence from creeping in due to knowing each other- a sensible strategy.
And now the First Officer: "Description of the experiences and impressions of Flight 4 U 753
"After a 3h long turn-around in VIE due to the closure of CGN airport, we were finally able to takeoff. We had a tight slot, the guests began boarding , the second bus was taking its time. Eventually the second bus arrived; snow was falling, we had to be de-iced at the remote position with running engines. The "after start items" were accordingly not executed.
During de-icing I said (jokingly) to CM1: "I would always have an ear for you, if you want to tell me something." The TO briefing was forgotten in transit despite sufficient time. After de-icing we were ready to go and CM1 requested the TO checklist. A short objection from me, if we shouldn’t first do the After Start Items followed by the list, was gratefully accepted. We were back in the loop and both were in sequence for TO. The TO followed and CM1 was PF.
TO and CRZ were both unspectacular. We approached CGN and started the descent. My thoughts at that time: "Ok, altitude 5000 ft, everything safe, we have briefed, Wx radar is running, watch out with 3000 ft and the MSA, don't forget the below MSA callout.“
We had now flown over WYP and had the clearance to drop to 3000'. Arriving at 3000' and turning on to baseline I thought again: "OK, lights are on, RAD Nav set, approach phase active, watch out with the MSA outside of 15 NM." On the turn to base CM1 said: "Do you smell something?" - "Oh yeah, that's a really strong smell. That smells really electric and sweetish" - "Yeah, I think so, it's definitely electric. We are watching this!"
By now we were on base-heading and for me the smell was gone - I didn't notice it anymore. CM1 confirmed this to me by saying: "Yes, now the smell has become much weaker." I agreed with a "jep" and then I didn't notice it any more. This was the last moment everything was normal.
How often have you smelt something electric in the Airbus for a short time, which disappeared shortly afterwards? But now the events were about to start happening very fast and the momentum of this situation was way more than I had ever experienced in my training in Bremen, when an instructor wanted to push you to the limit, nor later on line in any LOFT scenarios. The dynamics that develop in our Smoke and Fire Refreshers seem to me to be peanuts.
"GWI 753, turn left Heading 170, cleared ILS 14L" - "GWI 753, left turn heading 170, cleared ILS 14L".
The HDG was quickly turned on and the APP mode was set. While the plane started to turn the smell returned. I said: "The smell is back" - "Yes, I can smell it, too." At the same time, I got nauseous, like somebody just punched me in the stomach. Simultaneously , my arms and legs felt numb and I felt like I'd been drinking hard. I shouted, "I feel sick, I'm gonna put the mask on!" –„Oh yeah, I can feel it too, I'll put it on too!".
I took out the mask and thought of the refresher I had the week before: "Headset in the neck, mask on, headset." But it wasn't until the second try that I got it right. The plane was turning at that moment and the LOC followed. At the same time the following things happened in my head:
"Remove protective film from mask."
"FUCK! What's happening?"
Communication was quickly established, we briefly confirmed each other's status. "I feel a bit better", CM1 said. I answered with: "I'm still feeling bad." This condition was to stay that way and even get worse later. In the meantime we were LOC established on a 12 NM final, speed 220 selected.
CM1: "Tell him we're switching to TWR pilot and call MAYDAY!"
CM2: "Controller, GWI 753, we switch over to TWR."
ATC: "OK, GWI contact 12497"
CM2: "CGN TWR GWI 753, Mayday, Mayday, Mayday, we’ve got a strong smell in the cockpit. Standby!"
"CGN TWR 753, copied, confirm you have fire in the cockpit?"
„Negative, we have strong smell in the cockpit, standby.“
The controller recognized by the tone of voice the urgency for the change to TWR and was immediately cooperative. The TWR controller’s voice to me was in the first moment sounding somewhat astonished and during later radio messages clearly more urgent.
After I had sent the radio message, I told CM1 that everything was done. "OK, I've sent word." - "OK, thanks, but while you were transmitting, I put the flaps on I.“
I hadn't noticed anything about that, I only noticed at the beginning of the radio message series that CM1 had disconnected from AP and was flying manually, which was much more comfortable for me than flying with AP.
The G/S went in while I was communicating and CM1 had set the flaps to I. We were clearly too fast, so CM1 commanded: "Gear down!" - "Gear down!" - "Flaps 2“ – „Flaps 2".
The speedbreak was clearly pulled. My thoughts at that moment:
"Huh? Why are the flaps on 1? Why is the gear down already? Flaps 2, now? Hey, where are we now, anyway? Never mind, we're on LOC and GS, we follow the needles, there's a trajectory down there. Flaps 2, gear's coming up! But that's already down? HUH??"
We were at 100ft, the runway clear ahead of us. "Oh yes, there it is, hopefully we can make it, it's almost done! All these fire engines everywhere.“
I couldn't really process the information.
At the same time I heard the radio call from TWR controller: "Easyjet ..., GO AROUND, GO AROUND!“
I can't remember if there was any readback from the Easyjet at all. I could not swear that it was really an Easyjet ...
"GWI 753, runway 14L, cleared to land."
"Flaps 3. Flaps 3."
"Flaps full - Flaps full"
CM2: "The 1000ft gate, can we make it?
CM1: "Emergency clearance, 1000ft gate doesn't matter. Go around is no option".
We were somewhere at 1800 ft, I think, and then this eternal emptiness started. The moment where you might still read the LDG checklist and concentrate for 2 minutes until touchdown. Normally at that moment you routinely look at the instruments and the scan runs automatically.Those 2 minutes felt like an eternity.
"Shit, I hope we make it, I can't go on, I don't know where we are, oh God, let us land safely, please let us survive this. What the fuck else can I do?"
I noticed through the habit patterns that VIs and Vapp were right. I also noticed we hadn't read the LDG checklist.
"LDG checklist?“ – „LDG checklist!“ – „LDG: All green, flaps full. All green, flaps full."
We were now at 1200 feet, still half an eternity from touchdown.
"Oh, God, I feel so bad. What's wrong with my arms and my legs? I can't feel anything. What should I do next? Check REV green, spoiler's deccel high! Oh man, this has gotta be a dream, please CM1 land the bird, I can't fly."
I felt like I wasn't able to fly any more. I felt it to be utterly exhausting to scan the instruments, how hard it was to think, how hard it was to even concentrate. But most of all I felt the fear that we could not make it and the simultaneous will to get the "shit" plane on the runway. Target fixation?
I didn't even hear or notice the 100 above call. But I had heard the "minimum" call. I said, "Continue?". There was no answer. "CONTINUE?". Still no answer. "Shit, what’s up with CM1?" One look at CM1 and I saw that he was still there and was flying. Also the corrections on the PFD were according to the FD. A short time later I heard a "CONTINUE!!! !". Relief spread, CM 1 was there!
We were in 100ft, the runway clearly in front of us. "Oh yeah, there it is, hopefully we can make it, it will be over soon! Wow, all those fire engines everywhere!"
The touchdown followed, the gear set down hard, the speed was about 5 kts over Vapp, the REVs turned green, the spoilers came out and the deccel light went on at autobreak med. Relief was spreading. "Damn it, concentrate, it's not over yet!"
The plane started to slide on the runway, we both noticed it clearly.
CM 1: "We can't make A3!"
For some reason, I thought we could make it. I saw the fire engines crossing runway 24 via TWY A. I said to TWR: "We take A3!"
I think CM1 braked with his feet at 40 kts, we skidded, but we still managed A3. We rolled off the runway, forgot the after landing items and were now on TWY A. CM1 said: "I'll give you the plane, you taxi, I'll talk to the fire department, frequency 123.1. You have control!“ – „I have control“.
God, I felt so bad at that moment, I still felt as I had described at the beginning: the extremities numb, the senses clouded and now I was taxiing. I felt overwhelmed, but I thought I could do it. I had taxied twice so far: once in line training and later on CM 1 let me roll a straight stretch.
Shortly afterwards ATC called: "GWI 753, continue A, C7", CM2: "GWI 753 A, C7".
I fully concentrated on the taxiing and did not notice how CM1 was spoking with the fire brigade. In the meantime I didn't think anything anymore, I was fully concentrated on taxiing.
"GWI 753, I'd like to have you on an outside position, I'm not allowed to let you at the gate, so taxi A, B, A9" - CM2: „GWI 753, ABA9“.
In the meantime we turned left onto TWY B. CM1 called again and said: "OK, A09, I have also discussed with the fire department.“ I confirmed that this was also the instruction of the pilot. On TWY B CM1 said: "I have control“ – „You have control!"
We rolled behind a Follow-Me and said that we would not take off the mask until we got the windows open at the position.
We rolled, got to A09 and just before we stopped, I said that we hadn't done the after landings. "Yup, after landing items." Said, done... And now engines off, beacon off. I don't remember how we had read the parking list, I just know that I had done this by memory with regard to fuel flow, ND and triple indicator and I shouted this out loud.
Now I wanted to open the window. It took me 3 attempts. On the second try I thought: "Fuck, what's wrong with this fucking window!" I leaned into the seat and I thought: "Slowly, once more, concentrate. Push the lever, pull it towards you." I took a deep breathe from my mask and on the third try, it worked. I took the mask off and immediately noticed the acrid smell again and put the mask back on. Thereupon I leaned out of the window and took off the mask. I saw two people with vests outside waving at me and shouting something at me, but I didn't understand anything. The only thing I noticed was that CM1 was making an announcement to the guests.
After enough fresh air I wanted to get back into the cockpit, sitting in my seat I noticed that the PU was coming in; when the seatbelt signs were switched off, I don't remember.
Suddenly a fireman was there, I got up, he grabbed me under my arm. I don't know how I said, "I can manage!". But I noticed how wobbly my legs were and how weak I felt. He led me down the stairs to the ambulance. He led me past the passengers and I saw with what horror the passengers, especially a woman in the second row, stared at me and I thought: "Oh, the poor guests, what must they think of us now...".
In the ambulance I was treated with oxygen, my O2 saturation level was just below 80%. The normal value of a person without a chronic illness, as I learned later on, is 94-98%.
I was still feeling bad. The saturation level stabilized after about 15 minutes. A felt eternity later - in fact it was about 20 minutes - CM1 came in and I noticed how he was still in "working mode" and suddenly switched off. His oxygen content was much lower at around 70%. I can still remember the paramedic saying: "There wasn't much missing until he would have fainted!"
We were driven to the hospital and treated and released 2 hours later. The next day, when they told me that the de-icing fluid might have been the cause, I went back to the hospital in consultation with the poison institute and had a complete examination with special attention on glycol.
Organs were OK, blood values were not. One did not know whether this was due to sports, intoxication or a mixture of both. To this day I don’t know, and I am still under medical observation and continue to be cared for by CISM.
I can't imagine if we had been knocked out! The plane would have followed the LOC and GS and hit the ground in Cologne with 8 tons of remaining fuel (because of snow) - and 144 guests + 5 crew members. I still don't want to imagine the catastrophe.
I'm sure that the reason why I found it so easy to reach for my mask was that the hierarchy gradient was only a slight gradient from left to right and the atmosphere in the cockpit was very good and professional. I define a good cockpit atmosphere for myself when I feel that mistakes are perfectly OK. Furthermore it was very nice for me that CM1 waited at the cockpit briefing until I had packed everything and went to the cabin briefing together with me. So it was also easier for me to have confidence in my captain. I am sure that this good atmosphere and the trust in the captain contributed to the fact that we got through it so well. On that day we were definitely a team! Otherwise I don't think we would have made it through this day...
I can imagine that perhaps some people might think that as FO you have a duty to act when we notice something serious. However, this is easier said than done! I would like to take the opportunity to point out that the hierarchical differences and atmosphere can be a clear inhibition threshold for us FOs to take the initiative. I have experienced this in a number of other situations so far.
I would also like to thank my CPT for continuing to keep in touch with me after the incident and still does. I have always had the feeling, even a few days after this incident, that we are one crew. This is very important for me as a young FO!
Up until this incident I always felt that if I pay enough attention, keep up the situational awareness, everything will go well. But this incident shows that, as written in the OM-A, we must always know what we are doing and be able to take the plane in hand at any time and, if necessary, be able to make ad hoc decisions. For this we must be rested and have a clear head. Looking back on my young FO career I don't know if I was really always rested ..."
At the German Bundesstelle für Flugunfalluntersuchung - BFU (same as the British AAIB or the FAA in the US) this process was not really taken seriously. It is not initiating any investigation as to whether this was - possibly - a "serious incident". The incident therefore - at first - does not appear in the statistics either.
Only one year later this fume event comes up again: in the Tourism Committee of the German Bundestag. Only now the BFU initiates an investigation when this "incident" has become known - at least in some political circles.
We have documented this incident in more detail in another context at www.ansTageslicht.de/Germanwings. There you can also read how the BFU acted afterwards.
The captain was able to fly again after only four days. The co-pilot was "not fit to fly" for over half a year.
Cockpit Flight Report No. 2: 22 October 2011 / London gatwick > Nurneberg
TUIfly, Boeing 737
The pilot in question (Captain, who had previously worked for four years as a mechanic for Lufthansa and is familiar with the technology of an aircraft) had been involved in two reported or a total of three fume events, all on the same aircraft. The first incident occurred 2 days before the first one he had reported as an accident, namely on October 18. At that time the pilot had not yet taken it seriously. The Cockpit Voice Recorder shows that this was the case.
Only when it happened again two days later did the captain make a report. Then on October 31st, the third incident. And only now did the technicians take a closer look at the aircraft. and found oil deposits in the auxiliary power unit. ...which is what we believe was present 12 days earlier.
We are documenting the first reported incident on October 20, 2011:
"On first leg NUE-LGW there was no odor detected.
On ground during turnaround at LGW there was a toxic/caustic smell in the whole cabin [APU bleed on, Packs auto, Recirc fan OFF]; there were two small peaks within a few minutes where the odor was intense. The capt and cabin crew were seated in Rows 3-6. I [capt] walked to the flight deck to check wether the APU had ingested gas from an external GPU, but there was none [a ground cable was connected]. I also confirmed that no other aircraft were starting their engines in our immediate vicinity. After confirring with the cabin crew we decided to leave the APU running despite the odors in the cabin. We felt it was better to be warm [outside air temp. 2° C] and accept the smell than freeze and have fresh air.
During taxi out there was a smell in Row 11-16; it improved with packs in HIGH and an increased N1 of 29% for about 3 min holding short of the runway.
Given the apparent improvement and after having confirred with the entire crew we decided to perform the takeoff under the condition that the cabin would be asked to check the cabin air quality passing 5000 ft. We felt this would affirm our suspicion that the APU was the source of the smell.
At first there was an improvement, than worse again. The smell was strongest in rows 11-16. it was especially intense in row 14D.
The cabin crew reported a few passengers had sniffed the air in an apparent attempt to identify an odor, but no one addressed this to the cabin crew.
During cruise flight the Capt. went through the cabin to aft galley to check the intensity of the smell. It was not extreme, but was definitely present. There was no indication that it might involve smoke; it seemed to come with the air flow from the air conditioning.
A smell was also identified in the aft galley. This was especially apparent in toilet 3L after a PAX came out. At first we thought it might be a perfume - but we checked the lavatory and were certain that it was the odor that we were investigating.
On the way back to the flight deck, I [capt] became weak in the knees obviously as a result of my exposure to the toxic smell.
Back on flight deck the copilot and I performed FORDEC about wether to divert to FRA or land in NUE. We decided to land at NUE due to high traffic at FRA, as we were only 18min away from TOD to NUE. We flew high speed, with shortcuts and a short ILS28 NUE.
At several points during the flight the captain used his quick-donning mask to try to clear his head with 100% oxygen after his exposure to the fumes. The odor was never detected in the cockpit except very briefly during taxi.
The first officer had remained in the cockpit for the entire flight and during the turnaround in LGW and was feeling none of the discomfort that the rest of the crew was beginning to feel. During our FORDEC we also concluded that the FO should remain on the flight-deck until NUE to ensure flight safety. After the return of the captain to the flight-deck the cockpit crew decided that the FO should remain PF for the rest of the flight to ensure a safe operation.
During flight we switched the recirc fan off [which was on since after eng start].
After cabin crew described the smell as a mixture of an oil and an electric smell, we switched off galley power/IFE switch [at DAHIA both on galley pwr switch].
During taxi-in we decided not to make an announcement and possibly unnecessarily upset the passengers since none of the passengers had mentioned any smell or discomfort.
After deboarding the technician came aboard and immediately noticed an oil/ electrical smell in the whole aircraft. [in his opinion a tendendency to electric smell.]"
Cockpit Flight Report No. 3: 3 September 2017 / London Heathrow > Leipzig
Cargo Flight Airbis A 300-600
The pilot (captain), which we abbreviate with his agreement with MK, was basically aware of the potential problem of contaminated cabin air or fume events. But as it is: He himself could not imagine that one day it could get him.
The same applied to his co-pilot, R.... He was not prepared for such a thing at all, had never really heard of it, although he had been flying for quite a while. Not all pilots know about it. There is no mention of it in their training. MK knew about it because he had worked as an aircraft mechanic before he became a pilot and therefore knew about the problem of "bleed air", which is tapped directly from the hot running engines and then distributed from there via a pre-cooler to the various distributors of the air conditioning system in the cabin.
Luckily, both of them had put on - at the last second so to speak - the saving oxygen masks that are only available for pilots. What a passenger is told by the flight attendants before take-off when explaining the safety regulations, namely that "oxygen masks" would automatically open in the event of a drop in pressure, is sheer deception. These masks allow the same air to pass through as that in the cabin. Only the pilots have real "oxygen". Even the flight attendants do not have such a thing. To take oxygen cylinders with you for each would mean a huge increase in weight.
But despite the "oxygen mask": The fact that the machine comes to a stop in time after the touch-down is thanks to the autopilot. Leipzig Airport is prepared for this technology.
Here is the experience report of Captain MK:
"We were on D-AZMO on a flight from LHR to LEJ on September, 2nd, 2015. I flew this airplane the two previous flights as well:
BCS1893 BRU-LTN and BCS758P LTN-LHR.
On BCS1893 in the early morning we encountered oil smell 1-2 minutes after T/O. I gave it a try and switched Pack1 off. A few moments later the oil smell disappeared.
We continued this short flight into LTN with no further smell events.
After the landing I did an entry in the ATL concerning the oil smell of Pack1 and the engineer transferred it into the Hold Item List considered as INOP.
The next flight into LHR in the evening was uneventful.
Now to the flight of concern.
A few minutes after we took of in LHR we had again oil smell. This happened now with the remaining Pack 2. We waited a moment as the smell intensity was increasing. At the moment as the smell got more intense than on BCS1893 I decided to switch Pack1 on and Pack2 off. We again waited a moment if there is any improvement, and there it was. Here I want to mention that the whole time we had only oil smell and no haze, fume or even worse. Neither we had physical problems at all.
So a probable return or a diversion came never into my consideration at that moment.
The air quality was improving and for a few minutes we had no oil smell.
Another 5 to 10 minutes later, may be it was reaching cruising altitude which is coincidental with power change, it got worse again.
So I switched Pack2 back on and Pack1 off.
The obvious smell disappeared again and we thought it is okay for the moment.
After maybe 45 minutes in flight I felt a little strange in my stomach, experienced worsening headache. I got up to use the restroom. When I started walking I felt a little dizzy like drunken.Still I was not aware that my physical condition was slowly weakening. Otherwise I would have taken the mask earlier. I asked Rateb, the First Officer if he is experiencing any physical abnormalies. He said, he is feeling tired due to the time of the day and as well he was already flying for six days.
As I returned into flightdeck we were already in the initial descent. I took over the controls. Suddenly the oil smell occurred again. Probably because of the change in power setting. As the smell got worse I switched again between the Packs but it did not improve anymore. At around FL230 I started the APU to get a hold of another air source. Again I switched between the Packs with no improvement at the end. So we kept the Packs off from now. We had been vectored short for RWY 08R via DP448 and been reduced by ATC to 220 Kts.
At FL140 I ordered Slats extend. As we reached FL110 Rateb was mentioning, we will not make the approach, because we were to high and due to the low speed we won't be able to get rid of the altitude.
So I ordered gear down. At the moment I ordered it I knew it would not had been necessary, in my opinion I was quite fine with my approach profile.
But also at this moment I felt a lack of being attentive enough to be ahead of the aircraft. At this moment we took the oxygen masks. We both were surprised how big the difference in quality of the cabin air to the oxygen was.Rateb had pressure like chest pain and a feeling of nausea was effecting him.This intensifying strong smell he had never before experienced during a flight.
Our physical condition improved a little bit but we both judged that it was not sufficent to land the aircraft manually. I decided to do an autoland.
As the aircraft did the flare I was even convinced that I were not been able to land the aircraft on myself. Accidently I overpowered the Autopilot in the rollout until I remembered to disconnect it to vacate the runway.
As soon we cleared the runway I shut down the R/H engine and asked Rateb to open his sidewindow.
Luckily we had stand 408 so we had a short taxi in.
Finally as Rateb did the parking and securing checks he mentioned that all switches were slimey like covered with an layer of oilfilm.
We told the arriving engineers about our encountered problem and the use of oxygen masks. They replied that obviously now the aircraft needs all engines and the apu replaced. After my question if there were other known cases of oil smell with this aircraft recently they answered they were some before.
When we were arriving at CSD we told them about our incident and that we are going into the hospital. They gave us an info page concerning our "Berufsgenossenschaft" and called a taxi for us.
Arriving in the Hospital we went directly to the emergency room and I told the nurse we had an aerotoxic event and if the hospital offers a procedure accordingly.
She agreed and called the doctor of duty. We had our examination from head to toe with given blood samples to figure out our values. At the end I found out, that they do not check ingredients of toxicination. As the doctor wrote our reports I went online to check if there is a urine sample required in this case. And there is.
Finally I asked the doctor if there is an urine sample required in their procedure and she denied, it would not be necessary. I insisted to take some urine sample of us to take with us for further examination which they did.
As a result of this severe incident and still suffering from some symptoms like dizziness, strange taste in my mouth and slow reactions my aeromedical doctor put me on certified sick leave for 2 weeks. She ordered me to make further appointments with a neurologist for follow up checks and to await the examination of the other taken blood and urine samples in different institutes.
Furthermore to all said above I have to mention that we can be happy that we had an aircraft and an airfield with autoland capability in this situation.
Otherwise the outcome might had happened a little different."
The German authority, the Bundesstelle für Flugunfalluntersuchung - BFU, had no choice but to include this incident in its statistics as a "serious incident" (Ref: BFU15-1289-5X - see p. 9). "Serious disturbance", however, "without any injured persons".
MK is now permanently unfit to fly due to his symptoms, short-term memory disorders, concentration difficulties, gastroenteric complaints as well as liver damage, balance problems, pulmonary fibrosis and small fibre neuropathy. Previously very healthy and a pilot for 23 years, now permanently ill and unable to work. With all social and financial consequences.
Because to this day, the Berufsgenossenschaft Verkehr, which is the employer's liablity insurance, has not recognised his case. And is not paying for any damages.
We have described his history in more detail elsewhere at www.ansTageslicht.de/niewiederpilot (German).
Cockpit Flight Report No. 4: October 2014 / Dusseldorf > Punta Cana
Long distance flight to Dominican Republik, Airbus 330-200
The pilot is (was) a "SFO": Safety Flight Officer. For long flights, three pilots are always required, so that you can take turns when sleeping briefly. Because of the many checks before and after a flight, as well as arrangements with the flight attendants, a pilot is always on duty several hours longer than the pure flight time. An "SFO" ensures that there are always two pilots awake at the controls.
We document here only the short summary, as it was sent to "BG Verkehr" (i.e. employer's liability insurance) as an "accident report". Here the SFO pilot very briefly describes his second fume-event experience. The first one was a year before and he had to stop for 3 months afterwards because of his persistent complaints.
It happened again in October 2014. And one year later, 2015, the SFO was involved in another two fume events. Then his job was over. Forever.
Here in a few sentences condensed how he felt in 2014:
" Strong odour pollution (oily, sweetish, synthetic) in the cockpit and cabin during and after an engine test run on the parking position in DUS, carried out by a technical staff member during our aircraft preparation.
Approx. 30 min. later when starting the engines ... again corresponding odour development, followed by headaches in the back of the head and pulling pain in the neck and shoulder area during the late steep flight.
Reduction of the odour to the limit of perception within about one and a half to two hours during the cruise flight, followed by pulling in the heart area, discomfort and increased dizziness. When getting up from the seat later, considerable stiffness in the hip area as well as in the knees, feeling of heaviness in the lower legs, slight numbness on the back of the hands, in the fingertips as well as in the face.
In the second half of the night in PUJ (meaning: Punta Cana, editor's note) in the hotel, increasing muscle twitching in different parts of the body. During the flight back to DUS without any noticeable odour, increasing muscle twitching, among others in the left rear shoulder area, where it could be video documented by me at home due to its local accumulation. Increased diastolic blood pressure, impaired circulation, breathlessness, especially in cases of spontaneous stress, bladder weakness, sleep disorders, problems finding words, concentration and memory, dizziness, etc. In the following days, detection of the harmful substances by means of human biomonitoring."
Note on the Cockpit Flight Reports
The fact that so little information becomes known has a system.
On the one hand, the reporting channels are not prescribed and certainly not standardised. Because the crew members know that their employers are anything but happy about such reports, this probably works as a first brake in most cases.
On the other hand, the Federal Bureau of Aircraft Accident Investigation (BFU), which is responsible for this, is also not in a very 'good mood'. As we know from the first flight report, it does not count all the reports that come in - it only reacted and started an investigation when the incident became known to some members of the German Bundestag (details: www.ansTageslicht.de/Germanwings).
In the cases Flight Report Cockpit No. 2 and 3, the fume events were classified as "serious incident", but in each case "without injuries".
We do not know whether the four Fume Events of the long-range SFO were even taken note of by the BFU. And so it is that the official statistics give very little. In other words, they completely distort the picture.
And that is also in the interest of the statutory accident insurance. Because this system is firmly in the hands of its sole financiers, which are the companies. In this case, the air transport industry.
The German GUV-system (Statutory Accident Insurance) is extremely cost-effective for the companies. As is well known, companies have to contribute to the social costs for an employee on a pro rata basis, e.g. to the contributions to the statutory health insurance (GKV). The proportionate employer's contributions quickly exceed 200 € per month.
The contributions to the GUV, which the employers have to pay for themselves, are considerably cheaper. They are graded according to hazard classes and average €25 per month across all sectors.
Airlines are particularly inexpensive: they pay an insurance contribution to the Berufsgenossenschaft Verkehr: 1.21 € per month and employee.
More information on this system is available at www.ansTageslicht.de/DGUV (German). How and what industry-led scientific research is working on and what has come out of it so far (similar to what happened with tobacco and asbestos) can be read at An Uncovering of Tricks, Methods and Strategies how to downplay fume events (EN). We have explained why the human body reacts differently at an altitude of 10 kilometres than it does down on the ground at What is different when we fly at 10 km altitude.