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Events from Jun 19th 1999 to Sep 22nd 2020 www.avherald.com Incidents and News in Aviation List by: Filter: Accident: Spirit A319 at Boston on Jul 17th 2015, fumes on board, captain died 50 days later

By Simon Hradecky, created Tuesday, Nov 6th 2018 21:03Z, last updated Tuesday, Nov 6th 2018 21:52Z During the research into the events surrounding the fume event of Jul 17th 2015 on board of N519NK for our first coverage The Aviation Herald came across several questions, one for example being, why neither FAA nor NTSB had any knowledge of the occurrence. Therefore we decided to look further into circumstances of the event. There were at least three ways to report the occurrence to the FAA:



1) The Aviation Herald knows that both pilots filed an according official report to the FAA.

2) The Air Traffic Controller must have noticed that the crew did not react correctly, even appeared to be confused, at one occasion turned into the wrong direction and donned their oxygen masks. Therefore it is more than likely that the controller filed a report too. (Editorial note: We'd appreciate if we could talk to the controller handling flight NK-708 on Jul 17th 2015 in private and ask the controller to contact us via the contact form)

3) Both flight crew donned their oxygen masks, hence this was a (compulsory) reportable incident, the airline was required to report the occurrence to the FAA



It is thus even more puzzling, that during our initial research as well as a specific FoIA request with respect to this occurrence the FAA reported that such an occurrence was not known and no records existed. Quite obviously the NTSB also was never informed about the occurrence as result, too.



We thus decided to expand our research with two objectives:



a) Review of how the FAA conducts oversight of airlines and aircraft operations with respect to fumes on the example of this airline

b) attempt to find out more about the circumstances and causes of the captain's death



Therefore we decided to file a FoIA request with the FAA concerning the captain and his history including medical records. The FAA Medical Center in Oklahoma City told us, they were not able to grant that FoIA request unless we could prove by a legally binding certificate of death, that the airman had deceased. We therefore approached the relevant authority with the request to receive a legal certificate of death for the captain. Usually such certificates are issued only to family members, the family however had indicated to be left in peace, which we respect of course. A clause in the law mentioned significant financial interest as another reason for issuing a death certificate which opened the door for us. We thus argued in our request keeping in mind a sentence out of the first officer's letter to his pilots' association stating "But to be clear: if I had not donned my oxygen mask on that July flight, we would have killed every person on the aircraft":



It is very clear, that had both pilots become fully incapacitated, this flight would have ended in a catastrophy most likely killing all on board. It is also clear, that a fume event like this can occur any time again, in fact, we know of at least a second event in Germany, where both flight crew were almost fully incapacitated at the time of touchdown and managed to maintain control of the aircraft with very last mental power reserves (Germanwings, Cologne/Germany, December 19th 2010, see Accident: Germanwings A319 near Cologne on Dec 19th 2010, smoke in cockpit, both pilots nearly incapacitated).



It is only a matter of time until such an event leads to the full incapacitation of both pilots on board and a subsequent crash resulting in both human tragedies and huge financial losses.



After quite some communication the authority granted our request about two months later. We submitted the certificate to the FAA Medical Center and subsequently received all documentation about the captain available at the FAA Medical Center.



The coroner wrote in the certificate of death as cause of death: "undetermined" and added while describing how the injury occurred: "unknown if external factors caused or contributed to death".



The FAA medical records showed, the captain enjoyed impeccable health, throughout his career he took no medications, none of the aeromedical doctors found any reason for concern or additional examination throughout the career until September 2014. During this examination the aeromedical doctor noted a "sinus Arrythmia (variation in P-R interval greater than 0.12)" but saw no reason to not issue the medical. In the very last medical examination, that took place about 4 months prior to the captain's passing, the aeromedical doctor found no reason to not issue the medical, however, requested a more thorough examination for the suspicion of sleep apnea.



We decided to file a FoIA request with the authorities of the captain's hometown to obtain the final report by the coroner, the request was granted and we did receive the autopsy report.



Little did we know at the begin of this research, that would put us in front of one of the most difficult questions a journalist will ever have to answer. Our findings into especially the last day of the captain were grim and would be able to destroy the memory of this fine man forever, on the other hand it is necessary to highlight what fumes can do to a human being. In the end I decided that the captain himself most likely would wish to help prevent others endure a fate similiar to his, and therefore it is necessary to reveal how extremely the 53 years old captain (at the day of his passing) changed after the fume event. Until the fume event the captain had always been reliable, trustworthy, friendly and skilled throughout his career of more than 30 years. His health had been impeccable. His reputation over all the years was impeccable, collegues were generally talking well about him.



However, following the fume event, after the captain returned to work following the fume event, the collegues noticed that the captain became increasingly dithering and unreliable. The captain lost eye and hand coordination as well as threedimensional perceiption. One day the captain parked his aircraft in such a way, that the crew taking the aircraft over the next day feared the captain might have been intoxicated.



And then the autopsy report starts mentioning that on the day of his passing the captain was about to be handcuffed by police when he collapsed and died. Police had been called on scene by witnesses reporting the captain had attempted to kidnap a woman on open street in the middle of their town and was in a physical struggle with her. When police arrived he attempted to flee and hide, but was caught.



The coroner stated he found: "No evidence of significant trauma (superficial blunt force injuries identified on head, torso, extremities; multiple injuries from resuscitative attempts)", "Microscopic evidence of acute myocardial infarction (24 hours or less in age)", "Cardiac interstitial and perivascular fibrosis" and added: "Possible exposure to organophosphates during airline flight, July, 2015".



In the discussion the coroner wrote: "The heart was enlarged, and further examination revealed severe coronary artery atherosclerosis, along with tunneling of a coronary artery. Microscopically, an acute myocardial infarction was identified. Toxicologic studies revealed a toxic/lethal level of tramadol in the peripheral blood." (Editorial note: Tramadol is an opioid based pain killer, which usually relieves of pain within an hour) The coroner mentioned that the captain had consulted with the emergency room one day prior to his death complaining about severe tremors and insomnia. The emergency room physician believed the tremors were due to stress and insomnia and discharged the captain, it appeared there was no prescription for Tramadol on that occasion.



The coroner subsequently concluded:



These circumstances suggest death via excited delirium, but tramadol is not known to cause excited delirium or an elevated body temperature. Also, there are no autopsy findings or laboratory tests that prove an individual died from excited delirium. Thus, if the decedent died because of excited delirium, it cannot be confirmed or excluded. It is also possible that recent exposure to organophosphates caused or contributed to death."



The autopsy was conducted to establish whether there was any link between the police activity and the death. The autopsy did not engage in further testing that would have been necessary to establish evidence of a causal link between the fume event and deterioration of health to the point of his passing. It appears to be a common observation, however, that victims of fume events may suffer from increasing pain over time, a high number of those victims even being driven to commit suicide to escape that pain as result of nerve damage, possibly in delirium.



Upon query whether additional laboratory results were not included in the report and would still be available for research by our medical advisors or whether perhaps even human tissue would be available for such research to investigate possible causal links to the fume event the authority responded, that no such evidence was kept or was available.



We already quoted Dr. Mulder in the first part of our coverage saying: "it is well known, that neurotoxic events produce myocarditis, and for that matter, myocarditis produces pulmonary embolism and sudden infarct/death." When Dr. Mulder was shown the full autopsy report he commented:



Our team has seen 7 post mortem cases of prematurely deceased airline personnel. 4 died of suicide, 3 of natural causes. However, all of them shared:



- a similar set of symptoms prior to their death, as described in a 2009 FAA funded Metastudy: EXPOSURE TO AIRCRAFT BLEED AIR CONTAMINANTS AMONG AIRLINE WORKERS, A GUIDE FOR HEALTH CARE PROVIDERS April 2009 (click to read)

- the same neuro degenerative damage to the brain and nervous system

- Their hearts showed an active lymphocytic myocarditis (LM). This can lead to arrhythmias and sudden heart failure.



Considering the fact that this airman has been exposed, during his flying career, to chronic uncontrolled low levels of burned oil products and heavy metal nanoparticles originating from the turbine engines is it most likely that the general damage was already present, considering his physical prior complaints and that the fume event was the drop that did overflow the bucket. Actual cause of death due LM cannot be excluded.



In our first part of the coverage we already introduced findings, that research into contaminated air as result of thermal decomposition goes back even into World War I. We already mentioned and summarized the study by the University of Cincinnati Aero Medical Laboratory conducted by Joseph F. Treon and collegues in 1954. However, research also went on within aircraft and jet engine manufacturers like Boeing, Douglas and Pratt&Whitney at least.



Douglas produced an internal paper on Jan 15th 1954, Report SM 15195 named "Engine Compressor Bleed Air Contamination Study XC-132 Project" with references to military studies going back to 1953. The study concerned the J57 engines by Pratt&Whitney, generally used in military aircraft, that subsequently evolved to become the JT3C engine used in commercial aircraft like the Boeing 707. The study concluded:



1. the temperature within the animal chamber during exposure significantly affected the results. The conclusions enumerated below are for a chamber temperature range of 80 to 55 degrees Fahrenheit.

2. In general, thermally-derived products of Samples Nos. MRD-67-10 and MRD-67-11 had the same order of toxic effect on exposed animals.

3. Of the three species used, rabbits were the least tolerant to the exposures.

4. Products thermally derived from either sample at 500 degrees Fahrenheit were less toxic than those derived at 700 degrees Fahrenheit.



Boeing produced an internal paper on December 18th 1953, document number D-14766-2 concerning the B-52, which used J57 engines, too. The study goes into great detail with various components of contaminations like Carbonyl, Oxidant, Formaldehyde and others and in particular tests various filters in the quest to introduce filters to protect against contaminated cockpit air. The study writes:



The second set of data to be discussed are from the laboratory smoke simualtor. Figure 27 shows the results of a serious of runs made for the specific purpose of evaluating carbonyl production against temperature. Note, that at a temperature of approximately 640 degrees Fahren the increase becomes very rapid. This temperature is probable lower in the engine as there runs were carried out prior to pressurizing the reaction chamber. However, the shape of the curve illustrates dramatically why the problem arose with new engines having higher compression ratios and why it may be expected to increase in severity in the future if oil leakage occurs.



However, although the problems of toxic thermal decomposites contaminating engine bleed air systems were known at the very latest in 1954, the use of bleed air based air conditioning systems were designed into jet engines and commercial airliners and were certified by the authorities, in particular by the FAA as regulator.



Most recent research, introduced at the "International Aircraft Cabin Air Conference 2017" in London,EN (UK) in September 2017, suggests, that cabin air is being contaminated on every single flight irrespective of odours or health effects occurring.



Prof. Dr. Scholz of Hamburg University of Applied Sciences, researching the function of seals in jet engines, stated, that engine seals leak oil by design in small amounts. This follows already from looking at the design of the engine bearing and their seals.



Prof. Dr. Heutelbeck of the University of Göttingen, Division of Occupation, Environmental medicine (now University of Jena), reported that patients - both passengers and crew - affected by fumes showed symptoms which were described in literature since several decades and can be seen up today. Regarding the findings of standardized diagnostic methods and human biomonitoring, related to these symptoms, the function failures in lung and nervous system are mostly incompatible with known diseases. Otherwise the symptoms appear plausible against the background of the toxicologically described properties of the substances and groups of substances that were detectable in the blood and / or urine near the time of the accident, however these groups of substances are not detectable in non exposed controls in that manner. Göttingen has only learned of this particular problem regarding over more than 4 years symptomatic patients after fume event. The function failures concern the oxygen intake, memory capacity and peripheral nerves. It is possible to prove malfunctions in these areas with standard tests, hence those humans suffer from measurable malfunctions. A rare malfunction for example is the reduced ability of the lung to absorb oxygen, which often occurs together with reduced capacity of memory and fitness, this is a highly specific combination related to cabin air incidents but incompatible with other known diseases. From Prof. Dr. Heutelbeck's point of view it is incomprehensible that these incidents of complaints and health disturbances on flying crews have not yet led to systematic investigations, although cabin air contaminations have been described since the 1950s.



While all of this our background research was ongoing, we received a good number of new fume event reports concerning the airline. We inquired with the FAA, spokeswoman Kathleen Bergen, about all of those events reported to us and received the replies that the FAA were looking into them. Several questions were left unanswered by Kathleen Bergen. On May 5th 2018 we therefore wrote within another inquiry: "BTW: I am still waiting for the infos regarding how the FAA perform their oversight over Spirit Airlines and how this accumulation of fume events as noticed especially during February came together."



In response Kathleen Bergen sent following statement to be attributed to the FAA, not herself as a spokeswoman:



The FAA is committed to protecting the safety and health of passengers and cabin crews on our nation's airlines. Studies have indicated that cabin air is as good as or better than the air found in offices and homes. The FAA believes that the cabin environment in the vast majority of commercial flights is safe. However, we are concerned that if certain mechanical failures occur, the cabin environment may contain contaminants. Airlines are required to report fume events to the FAA.



In total disbelief about this statement, which essentially said air in the cabin is as good or even better than the air in any home or office, we decided to deepen our research into the FAA oversight. We filed another FoIA request to the FAA now requring all occurrence reports as well as all FAA initiated supervision activities of the airline between Jan 1st 2015 and Jun 30th 2018.



On Oct 31st 2018 we received the reply to this FoIA request listing a total of 46 occurrences, however, no supervision activities were listed. We noticed immediately, all the fume events we knew about, even the fume events we had reported to the FAA, were missing in that list, only other occurences were listed. We inquired therefore: "I did notice that a lot of occurrences were not listed that we know about and even inquired with the FAA (Kathleen Bergen) about during 2018, notably all fume events are not listed. Is this outside your Data Systems Branch and tracked by some other office (and we are going to receive that list with a different mail), or what is the reason for this?"



FAA spokesman Lynn Lunsford replied: "Your request asked for occurrences, so she provided you with a list of all coded occurrences. The other events you mentioned might not have been coded as occurrences. It's possible that they might be able to find them with a more specific search. It's also possible that the information was reported through a voluntary safety information-sharing program such as ASAP. If that were the case, those records are exempt by law from disclosure."



We argued again that in particular this occurrence of Jul 17th 2015 was officially reported at least one time via the flight crew, likely was also officially reported by ATC Boston and was a serious reportable incident by the fact that both flight crew needed to don their oxygen masks with one being completely and the other nearly incapacitated and as such must have been reported by the airline.



We raised additional questions: "What does the FAA do with fume events? Are reports about such events all dismissed and thrown away? How many fume events, with or without injuries (please detail) have the FAA investigated in 2015-2017 (detail per year please) and have issued a final rule? How many of these fume reports 2015-2017 (per year) have been reported to the NTSB, how many of those were rated incidents, serious incidents or accidents?"



Lynn Lunsford replied, in reference to the FAA statement sent on May 5th 2018 by Kathleen Bergen: "After considering your additional questions, our previous statement stands. Good luck with your story."



We made a last attempt with respect to this statement essentially stating: "Studies have indicated that cabin air is as good as or better than the air found in offices and homes." and confronted both Lynn Lunsford and Kathleen Bergen with this FAA document:



Aircraft Cabin Bleed Air Contaminants: A Review by Gregory A. Day, Civil Aerospace Medical Institute, Federal Aviation Administration



This paper alone makes clear that the FAA statement "Studies have indicated that cabin air is as good as or better than the air found in offices and homes." does not hold water. On page 3 for example, and this was argued by us, the paper states, that the concentration of carbondioxide on board of aircraft had been determined to range between 519 and 4902ppm with an average of 1404ppm. In comparison, the concentration in office buildings averages at 400ppm. Many more papers to that theme are available.



Lynn Lunsford again responded: "We've said all we are going to say you on the matter. The FAA is not going to make anybody available for interviews. Good luck with your story."



Current regulations in the European Union, in particular EU Directive 89/391/EEC: Measures to encourage improvements in the safety and health of workers at work, define the hierarchy of control in working with possibly toxic agents:



1. The most effective option is to either eliminate the exposure hazard or substitute a hazardous compound for a less hazardous compound;

2. The next best option, if the exposure hazard cannot be eliminated, is to apply engineering control measures intended to mitigate the chemical exposure hazard by addressing the exposure at the source;

3. If engineering control measures are not sufficient, then administrative measures are useful to help to control/monitor the exposure;

4. And, as a last resort when exposure cannot be adequately controlled by other means, personal protective measures, including the use of personal protective equipment (PPE), are instituted. Where PPE is given to workers, they must be trained in its use.



In a letter to the Deutscher Bundestag (German parliament) Germany's Vereinigung Cockpit (VC), pilots' association, reminded the politics, that according to this regulation the problem of contaminated cabin air should not even exist as there are technical alternatives to bleed air available. Only if there were no technical alternatives available, filters would be acceptable as next best solution.



It is up to the readers to form a picture of how the FAA conducts oversight over airlines and aircraft operations with respect to contaminated cabin air, what conflicts of interest may exist as regulator (rule and law maker) as well as executive authority (overseeing airlines and operations) as well as operator (e.g. ATC services).

By Simon Hradecky, created Wednesday, Apr 4th 2018 10:14Z, last updated Monday, Apr 9th 2018 23:55Z



Both flight crew continued two more sectors the next day after a night's rest at a hotel, then both pilots went to see doctors. The captain was diagnosed with internal bleeding and abnormal blood values consistent with ToCP poisoning. Both flight crew were sick with diarrhea, vomiting, tremors, body shakes and feeling of tiredness that began to subside only after a couple of days.



The first officer returned to duty about a week later, the captain returned to duty a couple of days after the first officer, however, was described as unconcentrated and erratic throughout the following flights developing eye-hand coordination issues and increasingly unusual behaviour.



On Sep 5th 2015, 50 days after the occurrence, the captain died. According to the captain's family the official cause of his passing was a heart attack.



Dr. Michel Mulder, a former airline pilot for KLM and Aviation Medical Examiner for the FAA, has spent the last 10 years on fundamental research regarding long term effects of exposure to contaminated air in jet aircraft. During this time he and a team of scientists, performed 6 post mortem studies of prematurely deceased cockpit and cabin personnel. Strangely enough all six candidates show similar neuro-degenerative damage to the brain, heart and peripheral nervous system. The heart showed a normally rare disease called a catecholamine mediated Lymphocytic Myocarditis (Taka Tsubo). This may give rise to heart rhythm disturbances or sudden heart failure (see the



Dr. Mulder thus stated:



"it is well known, that neurotoxic events produce myocarditis, and for that matter, myocarditis produces pulmonary embolism and sudden infarct/death."



Medical literature about oil related heated fumes (typically developing smells described as odour of dirty old socks) goes as far back as World War I (1914-1918) and was further developed during World War II (1939-1945) in relation to heated fumes from Diesel engines e.g. in submarines. In 1954 (before the jet engines entered commercial aviation) a study of the University of Cincinnati Aero Medical Laboratory conducted by Joseph F. Treon and collegues showed, that even high doses of substances like being used in engine oils without thermal decomposition were "generally tolerated without untoward reactions". However, the thermal decomposition products formed from those substances at 700 degrees Fahrenheit (371 degrees Celsius) and inhaled in form of mist/fog even proved lethal in rather small doses. Countless further research papers were published since confirming, re-iterating and expanding such evidence.



The Aviation Herald only became aware of this occurrence in January 2018 while researching another recent fume event, see



Neither NASA, FAA nor NTSB databases have the event listed.



The NTSB reported on direct inquiry early February 2018 (still without us knowing the exact occurrence date, we only knew it was in July 2015) that they are not aware of any such occurrence.



After we were finally able to establish the exact date of the fume event, The Aviation Herald inquired with the FAA about the event but was told the FAA had no records. In disbelief The Aviation Herald filed a request for all materials concerning this occurrence under the Freedom of Information Act on Mar 6th 2018 including requesting the ATC recordings pertinent to the arrival of that particular flight NK-708 on Jul 17th 2015 into Boston as well as any filings made about the occurrence, on Mar 12th 2018 we received the reply stating: "A records search was conducted at Boston Airport Traffic Control Tower, Boston Terminal Radar Approach Control and Boston Air Route Traffic Control Center. Our searches revealed there are no records responsive to your request."



Having repeatedly inquired with the FAA about further fume events reported out of that airline and learning, that all of those events were unknown to the FAA, consequently filing a report with the FAA and receiving the reply: "Again, the FAA is investigating these incidents" we asked how the FAA conducted oversight over the airline in the light of such an incredible number of fume reports, however, this question was never responded to.



The airline did not respond to inquiries by The Aviation Herald. The first officer was directly contacted by The Aviation Herald, but did not respond.



On Jul 17th 2015 the two pilots had already completed two more sectors on this particular aircraft prior to the final fume event. They flew N519NK from Chicago to Minneapolis,MN (USA) as flight NK-761 and had encountered a relatively mild fume event after reaching the top of descent. The pilots discussed the event and whether to write it up in the technical log book, however, the captain decided to first return to Chicago before entering the event in the log book. On the flight back to Chicago, already flight NK-708, an even stronger odour of dirty socks appeared at the top of descent, passengers covered their mouths and flight attendants began to complain about feeling sick. After landing the odours were written up in the technical log, however, maintenance was unable to reproduce the odour. While the flight crew was considering what to do next, the assistant chief pilot of the airline boarded the aircraft and told the crew off, that they didn't know what they were doing and they were wrong in pushing for further maintenance action. The flight crew gave in and departed for the next sector. See the following paragraph and letter by the first officer for a detailed narrative of the fume event and following events.



Following the captain's passing the first officer wrote a



The first officer also gave a presentation to another pilot's association APA (Allied Pilots Association) on Oct 17th 2016 which was videotaped by APA, who gave us their friendly permission to carry that video.



On Apr 7th 2018 the first officer filed a copyright complaint with Youtube demanding the video to be taken down, Youtube complied with that request. We subsequently re-confirmed the legal situation with APA and received explanation that they were within their authority to grant permission for us to carry the video indeed, the video was done by APA and APA holds the corresponding rights. On Apr 9th 2018 we have filed a counter claim with Youtube as result, the first officer subsequently removed the copyright complaint in the evening of Apr 9th 2018. However, as APA understandably does not want to engage in a legal tit for tat, we respect their wish to have the video not distributed anymore and have removed the video itself from our coverage.



In this presentation the first officer re-iterated the narrative he gave in his letter to his pilot's union and revealed he had done extensive research on the topic of fumes reporting following facts amongst many others, that are also highly interesting:



- according to the Kansas State University Research there have been 5.3 fume events per 24,000 daily flights in the USA or 1955 fume events a year. However, only 6 fume events per year get reported to the FAA (see screen shot 1 of presentation below)



- Airbus received reports of bad smells during production flights on one specific aircraft type during specific flight phases regularly (see screen shot 2 of presentation below)



- The FAA does not require sensors to monitor bleed air (see screen shot 3 of presentation below)



- In previous times until mid 1990s fumes were often masked/camouflaged by cigarette smoke and thus remained undetected



- Symptoms range from dizziness, fatigue, sweating in mild poisoning to coma, heart block and death in severe poisoning (see screenshots 4.1 and 4.2 of presentation below)



- Symptoms can appear with a delay of 24-48 hours, neurologic symptoms can take even longer



- TCP, used as additives to all aviation engine oils to reduce wear, are not intended for consumption, acute symptoms include stomach cramping, muscle aches and sinus congestion which may be mistaken for flu or food poisoning and can lead to delayed onset of OPICN (OrganoPhosphate Induced Chronic Neurotoxicity). A captain and a first officer (editorial note: unclear whether the first officer meant this captain and himself) were diagnosed with "Effects from Cholinergic drug" after exposure to oil fumes (screenshort 4.3)



- In addition Hypemic Hypoxia can occur as result of exposure to e.g. carbonmonoxide causing reduced ability of the blood to transport oxygen although sufficient oxygen is available in the air (screenshot 5)



- Most pilots identify the odour of dirty old socks as a problem with the filters when in fact used turbine oils produce that odour. Lack of training, poor understanding, underreporting and weak FAA regulations cause understatement of the problem (screenshot 6)



- Most Fume/Smoke Checklists do not correctly address environmental control system fumes (screenshot 7)



- Possible solution: non-bleed aircraft like Boeing 787 or non-bleed options on other aircraft types (screenshot 8)



Screenshot 1 of presentation, 5.3 fume events per day, 1955 fume events per year in the USA (Screenshot: AVH/APA):





Screenshot 2 of presentation, Airbus receives regular reports of bad smells (Screenshot: AVH/APA):





Screenshot 3 of presentation, currently available onboard chemical sensors (Screenshot: AVH/APA):





Screenshot 4.1 of presentation, Symptoms (Screenshot: AVH/APA):





Screenshot 4.2 of presentation, Symptoms (Screenshot: AVH/APA):





Screenshot 4.3 of presentation, Symptoms related to TCP (Screenshot: AVH/APA):





Screenshot 5 of presentation, Hypemic Hypoxia (Screenshot: AVH/APA):





Screenshot 6 of presentation, Origin of dirty socks smell and underreporting (Screenshot: AVH/APA):





Screenshot 7 of presentation, Checklists (Screenshot: AVH/APA):





Screenshot 8 of presentation, possible solutions (Screenshot: AVH/APA):



A Spirit Airlines Airbus A319-100, registration N519NK performing flight NK-708 from Chicago O'Hare,IL to Boston,MA (USA), reached the top of descent into Boston when a strong odour of dirty socks occurred, both flight crew became aware of the odour. When ATC called to hand them off to the next frequency, both flight crew were unable to interprete the frequency and unable to select the new frequency until they finally managed to write it down after several repeats by air traffic control and process it from there. Operating increasingly erratically the first officer finally donned his oxygen mask, recovered a bit and recognized that the captain had sunk into his seat and was incapacitated. The first officer put the oxygen mask on the captain, too, who subsequently began to recover as well. The flight crew managed to land the aircraft without further incident, however, did not recall how they managed to land or taxi the aircraft.Both flight crew continued two more sectors the next day after a night's rest at a hotel, then both pilots went to see doctors. The captain was diagnosed with internal bleeding and abnormal blood values consistent with ToCP poisoning. Both flight crew were sick with diarrhea, vomiting, tremors, body shakes and feeling of tiredness that began to subside only after a couple of days.The first officer returned to duty about a week later, the captain returned to duty a couple of days after the first officer, however, was described as unconcentrated and erratic throughout the following flights developing eye-hand coordination issues and increasingly unusual behaviour.On Sep 5th 2015, 50 days after the occurrence, the captain died. According to the captain's family the official cause of his passing was a heart attack.Dr. Michel Mulder, a former airline pilot for KLM and Aviation Medical Examiner for the FAA, has spent the last 10 years on fundamental research regarding long term effects of exposure to contaminated air in jet aircraft. During this time he and a team of scientists, performed 6 post mortem studies of prematurely deceased cockpit and cabin personnel. Strangely enough all six candidates show similar neuro-degenerative damage to the brain, heart and peripheral nervous system. The heart showed a normally rare disease called a catecholamine mediated Lymphocytic Myocarditis (Taka Tsubo). This may give rise to heart rhythm disturbances or sudden heart failure (see the paper on "Autoantibody markers of neural degeneration are associated with post-mortem histopathological alterations of a neurologically injured pilot" by M.B. Abou-Donia, F.R.W. van de Goot and M.F.A. Mulder ).Dr. Mulder thus stated:"it is well known, that neurotoxic events produce myocarditis, and for that matter, myocarditis produces pulmonary embolism and sudden infarct/death."Medical literature about oil related heated fumes (typically developing smells described as odour of dirty old socks) goes as far back as World War I (1914-1918) and was further developed during World War II (1939-1945) in relation to heated fumes from Diesel engines e.g. in submarines. In 1954 (before the jet engines entered commercial aviation) a study of the University of Cincinnati Aero Medical Laboratory conducted by Joseph F. Treon and collegues showed, that even high doses of substances like being used in engine oils without thermal decomposition were "generally tolerated without untoward reactions". However, the thermal decomposition products formed from those substances at 700 degrees Fahrenheit (371 degrees Celsius) and inhaled in form of mist/fog even proved lethal in rather small doses. Countless further research papers were published since confirming, re-iterating and expanding such evidence.The Aviation Herald only became aware of this occurrence in January 2018 while researching another recent fume event, see Accident: Spirit A20N near Fort Lauderdale on Jan 28th 2018, fumes on board, crew feeling increasingly incapacitated which was followed by an incredible number of further fume event reports (most of which we did not cover but queried and filed reports with the FAA as they nearly reached "give us our daily fume event") as if a dam broke within the airline's staff after our January coverage. All of these reports included narratives of attempts to suppress write ups in the tech logs or reporting of such occurrences to authorities similiar to the first officer's narrative of this 2015 fume event. Ever since, also due to the reactions to our coverage, we were searching for and collecting evidence to verify this 2015 event. It was extremely difficult to even establish the exact date of the occurrence, then identify the aircraft to finally be able to file a meaningful inquiry with the FAA about the event.Neither NASA, FAA nor NTSB databases have the event listed.The NTSB reported on direct inquiry early February 2018 (still without us knowing the exact occurrence date, we only knew it was in July 2015) that they are not aware of any such occurrence.After we were finally able to establish the exact date of the fume event, The Aviation Herald inquired with the FAA about the event but was told the FAA had no records. In disbelief The Aviation Herald filed a request for all materials concerning this occurrence under the Freedom of Information Act on Mar 6th 2018 including requesting the ATC recordings pertinent to the arrival of that particular flight NK-708 on Jul 17th 2015 into Boston as well as any filings made about the occurrence, on Mar 12th 2018 we received the reply stating: "A records search was conducted at Boston Airport Traffic Control Tower, Boston Terminal Radar Approach Control and Boston Air Route Traffic Control Center. Our searches revealed there are no records responsive to your request."Having repeatedly inquired with the FAA about further fume events reported out of that airline and learning, that all of those events were unknown to the FAA, consequently filing a report with the FAA and receiving the reply: "Again, the FAA is investigating these incidents" we asked how the FAA conducted oversight over the airline in the light of such an incredible number of fume reports, however, this question was never responded to.The airline did not respond to inquiries by The Aviation Herald. The first officer was directly contacted by The Aviation Herald, but did not respond.On Jul 17th 2015 the two pilots had already completed two more sectors on this particular aircraft prior to the final fume event. They flew N519NK from Chicago to Minneapolis,MN (USA) as flight NK-761 and had encountered a relatively mild fume event after reaching the top of descent. The pilots discussed the event and whether to write it up in the technical log book, however, the captain decided to first return to Chicago before entering the event in the log book. On the flight back to Chicago, already flight NK-708, an even stronger odour of dirty socks appeared at the top of descent, passengers covered their mouths and flight attendants began to complain about feeling sick. After landing the odours were written up in the technical log, however, maintenance was unable to reproduce the odour. While the flight crew was considering what to do next, the assistant chief pilot of the airline boarded the aircraft and told the crew off, that they didn't know what they were doing and they were wrong in pushing for further maintenance action. The flight crew gave in and departed for the next sector. See the following paragraph and letter by the first officer for a detailed narrative of the fume event and following events.Following the captain's passing the first officer wrote a long letter (click here for the PDF) to his pilots' association (editorial note: for legal reasons we had to take a scan out of the book "Fume Event - The Aviation's Biggest Lie" by Porter Lafayette available on Amazon with friendly permission, having verified that the only difference to the original letter was the omission of the names of all involved persons, The Aviation Herald is in possession of a copy of the original letter) reporting what had happened and how the airline had told them off.The first officer also gave a presentation to another pilot's association APA (Allied Pilots Association) on Oct 17th 2016 which was videotaped by APA, who gave us their friendly permission to carry that video.On Apr 7th 2018 the first officer filed a copyright complaint with Youtube demanding the video to be taken down, Youtube complied with that request. We subsequently re-confirmed the legal situation with APA and received explanation that they were within their authority to grant permission for us to carry the video indeed, the video was done by APA and APA holds the corresponding rights. On Apr 9th 2018 we have filed a counter claim with Youtube as result, the first officer subsequently removed the copyright complaint in the evening of Apr 9th 2018. However, as APA understandably does not want to engage in a legal tit for tat, we respect their wish to have the video not distributed anymore and have removed the video itself from our coverage.In this presentation the first officer re-iterated the narrative he gave in his letter to his pilot's union and revealed he had done extensive research on the topic of fumes reporting following facts amongst many others, that are also highly interesting:- according to the Kansas State University Research there have been 5.3 fume events per 24,000 daily flights in the USA or 1955 fume events a year. However, only 6 fume events per year get reported to the FAA (see screen shot 1 of presentation below)- Airbus received reports of bad smells during production flights on one specific aircraft type during specific flight phases regularly (see screen shot 2 of presentation below)- The FAA does not require sensors to monitor bleed air (see screen shot 3 of presentation below)- In previous times until mid 1990s fumes were often masked/camouflaged by cigarette smoke and thus remained undetected- Symptoms range from dizziness, fatigue, sweating in mild poisoning to coma, heart block and death in severe poisoning (see screenshots 4.1 and 4.2 of presentation below)- Symptoms can appear with a delay of 24-48 hours, neurologic symptoms can take even longer- TCP, used as additives to all aviation engine oils to reduce wear, are not intended for consumption, acute symptoms include stomach cramping, muscle aches and sinus congestion which may be mistaken for flu or food poisoning and can lead to delayed onset of OPICN (OrganoPhosphate Induced Chronic Neurotoxicity). A captain and a first officer (editorial note: unclear whether the first officer meant this captain and himself) were diagnosed with "Effects from Cholinergic drug" after exposure to oil fumes (screenshort 4.3)- In addition Hypemic Hypoxia can occur as result of exposure to e.g. carbonmonoxide causing reduced ability of the blood to transport oxygen although sufficient oxygen is available in the air (screenshot 5)- Most pilots identify the odour of dirty old socks as a problem with the filters when in fact used turbine oils produce that odour. Lack of training, poor understanding, underreporting and weak FAA regulations cause understatement of the problem (screenshot 6)- Most Fume/Smoke Checklists do not correctly address environmental control system fumes (screenshot 7)- Possible solution: non-bleed aircraft like Boeing 787 or non-bleed options on other aircraft types (screenshot 8)Screenshot 1 of presentation, 5.3 fume events per day, 1955 fume events per year in the USA (Screenshot: AVH/APA):Screenshot 2 of presentation, Airbus receives regular reports of bad smells (Screenshot: AVH/APA):Screenshot 3 of presentation, currently available onboard chemical sensors (Screenshot: AVH/APA):Screenshot 4.1 of presentation, Symptoms (Screenshot: AVH/APA):Screenshot 4.2 of presentation, Symptoms (Screenshot: AVH/APA):Screenshot 4.3 of presentation, Symptoms related to TCP (Screenshot: AVH/APA):Screenshot 5 of presentation, Hypemic Hypoxia (Screenshot: AVH/APA):Screenshot 6 of presentation, Origin of dirty socks smell and underreporting (Screenshot: AVH/APA):Screenshot 7 of presentation, Checklists (Screenshot: AVH/APA):Screenshot 8 of presentation, possible solutions (Screenshot: AVH/APA):

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