cabin smoke, fire, fumes, or odor incidents - aviation safety

ASRS Database Report Set

Cabin Smoke, Fire, Fumes, or Odor Incidents

Report Set Description .........................................A sampling of air carrier reports concerning cabin smoke, fire, fumes or odor related events.

Update Number ....................................................11.0

Date of Update .....................................................June 28, 2017

Number of Records in Report Set ........................50

Number of New Records in Report Set ...............50

Type of Records in Report Set .............................For each update, new records received at ASRS will displace a like number of the oldest records in the Report Set, with the objective of providing the fifty most recent relevant ASRS Database records. Records within this Report Set have been screened to assure their relevance to the topic.

National Aeronautics and Space Administration

Ames Research Center Moffett Field, CA 94035-1000

TH: 262-7

MEMORANDUM FOR: Recipients of Aviation Safety Reporting System Data

SUBJECT: Data Derived from ASRS Reports

The attached material is furnished pursuant to a request for data from the NASA Aviation Safety Reporting System (ASRS). Recipients of this material are reminded when evaluating these data of the following points.

ASRS reports are submitted voluntarily. The existence in the ASRS database of reports concerning a specific topic cannot, therefore, be used to infer the prevalence of that problem within the National Airspace System.

Information contained in reports submitted to ASRS may be amplified by further contact with the individual who submitted them, but the information provided by the reporter is not investigated further. Such information represents the perspective of the specific individual who is describing their experience and perception of a safety related event.

After preliminary processing, all ASRS reports are de-identified and the identity of the individual who submitted the report is permanently eliminated. All ASRS report processing systems are designed to protect identifying information submitted by reporters; including names, company affiliations, and specific times of incident occurrence. After a report has been de-identified, any verification of information submitted to ASRS would be limited.

The National Aeronautics and Space Administration and its ASRS current contractor, Booz Allen Hamilton, specifically disclaim any responsibility for any interpretation which may be made by others of any material or data furnished by NASA in response to queries of the ASRS database and related materials.

Linda J. Connell, Director NASA Aviation Safety Reporting System

CAVEAT REGARDING USE OF ASRS DATA

Certain caveats apply to the use of ASRS data. All ASRS reports are voluntarily submitted, and thus cannot be considered a measured random sample of the full population of like events. For example, we receive several thousand altitude deviation reports each year. This number may comprise over half of all the altitude deviations that occur, or it may be just a small fraction of total occurrences.

Moreover, not all pilots, controllers, mechanics, flight attendants, dispatchers or other participants in the aviation system are equally aware of the ASRS or may be equally willing to report. Thus, the data can reflect reporting biases. These biases, which are not fully known or measurable, may influence ASRS information. A safety problem such as near midair collisions (NMACs) may appear to be more highly concentrated in area “A” than area “B” simply because the airmen who operate in area “A” are more aware of the ASRS program and more inclined to report should an NMAC occur. Any type of subjective, voluntary reporting will have these limitations related to quantitative statistical analysis.

One thing that can be known from ASRS data is that the number of reports received concerning specific event types represents the lower measure of the true number of such events that are occurring. For example, if ASRS receives 881 reports of track deviations in 2010 (this number is purely hypothetical), then it can be known with some certainty that at least 881 such events have occurred in 2010. With these statistical limitations in mind, we believe that the real power of ASRS data is the qualitative information contained in report narratives. The pilots, controllers, and others who report tell us about aviation safety incidents and situations in detail – explaining what happened, and more importantly, why it happened. Using report narratives effectively requires an extra measure of study, but the knowledge derived is well worth the added effort.

Report Synopses

ACN: 1441096 (1 of 50)

Synopsis PC-12 Captain reported a burning oil odor with no visible smoke after takeoff. Unable to

determine the source, the crew returned to land.

ACN: 1441035 (2 of 50)

Synopsis EMB-145 flight crew reported they noticed a strong burning odor in the cabin and elected

to divert. The odor dissipated during descent.

ACN: 1438894 (3 of 50)

Synopsis A330 Flight Attendant reported smelling a burning odor and observed haze in the cabin

after takeoff.

ACN: 1438809 (4 of 50)

Synopsis CRJ-900 Captain reported fumes in the flight deck. They elected to divert to the nearest

suitable airport.

ACN: 1437931 (5 of 50)

Synopsis A330 Flight Attendant reported a potent smell in the aft section of the aircraft while

performing pre-flight duties. Eventually the entire crew was negatively affected by this

odor.

ACN: 1437899 (6 of 50)

Synopsis Air Carrier Dispatcher reported he was advised by a wide body flight crew that they were

on a taxiway dealing with a possible engine fire that had been reported to them by the

Tower.

ACN: 1437845 (7 of 50)

Synopsis A319 flight crew reported fumes in the flight deck. After a short time they began to

experience problems concentrating and the onset of incapacitation.

ACN: 1437759 (8 of 50)

Synopsis B777 flight crew reported seeing and smelling acrid smoke accompanied by an EICAS

message regarding smoke detected in crew rest area after takeoff.

ACN: 1437680 (9 of 50)

Synopsis BE20 pilot reported detecting a burning plastic smell on taxi. After shutdown, the odor was

attributed to an overheated flap motor.

ACN: 1437220 (10 of 50)

Synopsis A319 First Officer reported the entire flight and cabin crew felt physical effects from the

fumes and odor of unknown origin in the aircraft.

ACN: 1436838 (11 of 50)

Synopsis An A319 Captain reported detecting a faint, strange, sweet odor during after takeoff and

again during approach. Both pilots and two flight attendants reported being light headed

with headaches and sore throats for which they received medical attention. Number one

engine had recently been overhauled.

ACN: 1436565 (12 of 50)

Synopsis A330 First Officer reported smelling oil fumes in the flight deck. A few hours after the flight

he reported severe fatigue and a headache that has lasted 31 days.

ACN: 1435935 (13 of 50)

Synopsis B737 flight crew reported a dirty sock smell after beginning to taxi for takeoff. The flight

returned to the gate and the pilots were transported to a hospital.

ACN: 1435678 (14 of 50)

Synopsis A320 Flight Attendant reported a "dirty sock" smell in the rear of the aircraft shortly after

takeoff. The Captain was informed and the flight returned to the departure airport.

ACN: 1435356 (15 of 50)

Synopsis

B777-200 flight crew reported they aborted a takeoff and evacuated the aircraft due to a

FIRE CARGO AFT annunciation. Post flight inspection determined a pneumatic duct had

failed.

ACN: 1434798 (16 of 50)

Synopsis EMB145 Captain reported that during flight there was an electrical odor such as

overheating wires or insulation.

ACN: 1434100 (17 of 50)

Synopsis Dash 8 flight crew reported returning to departure airport after the Engine Fire Detect

warning light illuminated.

ACN: 1434081 (18 of 50)

Synopsis EMB-145 First Officer reported returning to the departure airport after noticing an

electrical smell and receiving a master warning for lavatory smoke.

ACN: 1434014 (19 of 50)

Synopsis B777 crew reported returning to the departure airport shortly after takeoff due to fire

detection and smoke alarms with visible smoke on the flight deck and cabin.

ACN: 1433712 (20 of 50)

Synopsis B737 flight crew reported discharging the APU fire bottle when residual fuel from a failed

start created the appearance of a fire during the APU start.

ACN: 1433693 (21 of 50)

Synopsis B737 Captain reported a diversion due to an aft cargo fire indication. The cargo bin was

inspected and no smoke nor fire was observed.

ACN: 1433441 (22 of 50)

Synopsis B737 flight crew was informed by a Flight Attendant that there was smoke in the aft cabin

after gate arrival. The problem was traced to a faulty potable water system compressor.

ACN: 1433294 (23 of 50)

Synopsis C172 instructor pilot reported detecting exhaust fumes while in the traffic pattern and

elected to depart the pattern and return to home base.

ACN: 1433144 (24 of 50)

Synopsis B737-800 Captain reported the landing gear lever was moved to the down position at a

speed higher than authorized during a rapid descent.

ACN: 1433099 (25 of 50)

Synopsis EMB-175 flight crew reported a passenger's portable battery overheated so the Flight

Attendant placed the battery in a water container as per company procedure.

ACN: 1432636 (26 of 50)

Synopsis BE-400 Captain reported that they received a "Battery feeder fail" master warning due to

an electrical fire in the tail section.

ACN: 1432106 (27 of 50)

Synopsis BE400 Captain reported a complete electrical failure shortly after takeoff, rendering PFD's,

trim, landing gear and flaps inoperative. Emergency gear extension was used to lower the

landing gear and emergency brakes used to stop the aircraft.

ACN: 1431799 (28 of 50)

Synopsis The flight attendants on an Airbus A330 reported that there was a very strong odor in the

cabin after takeoff.

ACN: 1431757 (29 of 50)

Synopsis A330 flight crew reported returning to departure airport after "dirty socks" fumes were

reported in the cabin.

ACN: 1431443 (30 of 50)

Synopsis

A321 Flight Attendant reported smoke and fumes in the cabin and experienced illness after

the event.

ACN: 1430620 (31 of 50)

Synopsis A321 Flight Attendant and Captain reported smelling a strong burn-off or fuel smell during

takeoff, then once again after landing.

ACN: 1430618 (32 of 50)

Synopsis Four B757 flight attendants reported two fume events at the gate prior to push back. After

the second event the flight attendants were taken to the hospital and the aircraft was

taken out of service.

ACN: 1430527 (33 of 50)

Synopsis The flight attendants of an Airbus A330 reported a musty sock odor in the cabin during

takeoff and continued during flight. Many required medical attention.

ACN: 1430524 (34 of 50)

Synopsis A321 Flight Attendant reported a strong odor in the cabin during cruise resulting in

physically ill symptoms.

ACN: 1430484 (35 of 50)

Synopsis A330 flight attendants reported an aircraft evacuation at the gate due to heavy smoke in

the passenger cabin.

ACN: 1430480 (36 of 50)

Synopsis A320 Flight Attendant reported that cabin fumes became unbearable during the flight,

resulting in illness.

ACN: 1430444 (37 of 50)

Synopsis A321 Flight Attendant reported a strong odor in the aircraft during boarding. When many

passengers and cabin crew members began to feel ill, the Captain decided to have the

passengers exit the aircraft.

ACN: 1430346 (38 of 50)

Synopsis Cabin crew reported strong fumes in the cabin after application of take off power, that

resulted in a return to the departure airport.

ACN: 1430291 (39 of 50)

Synopsis A330 Flight Attendant reported an odd odor in the cabin that resulted in physical

symptoms related to the odor.

ACN: 1430284 (40 of 50)

Synopsis A321 Flight Attendant crew reported a strange odor on the aircraft during descent, all crew

members affected and went to the hospital. Lead Flight Attendant recommended that they

should also be trained to use portable oxygen during fume events.

ACN: 1430267 (41 of 50)

Synopsis A320 cabin crew reported a failure in the hydraulic system while taxiing resulted in smoke

in the cabin and a subsequent call by the Captain to evacuate.

ACN: 1427425 (42 of 50)

Synopsis PA-23-250 pilot reported he climbed through his ATC assigned altitude when his gyro CB

popped.

ACN: 1426678 (43 of 50)

Synopsis A319 Captain reported an APU auto shut down at the gate due to low oil quantity. The APU

was deferred, but later, Maintenance determined that leaking oil likely caused fumes in the

cabin on previous legs with a different crew.

ACN: 1426650 (44 of 50)

Synopsis A CE-560XLS flight crew reported smoke and fumes on descent so the crew diverted to a

nearby airport. Maintenance found a burned set of wires under the forward left galley

carpeting and believe that to be the smoke's source. The First Officer commented about

the aircraft emergency checklist complexity.

ACN: 1425790 (45 of 50)

Synopsis C421 pilot reported returning to departure airport after noticing smoke and decreasing oil

pressure associated with the right engine.

ACN: 1425561 (46 of 50)

Synopsis A319 Captain reported an extract fan failed, caused smoke and fumes in the cockpit. Flight

diverted short of destination.

ACN: 1424990 (47 of 50)

Synopsis Beach 1900 Captain reported a burning smell and smoke coming from behind the glare

shield.

ACN: 1423970 (48 of 50)

Synopsis RV-8 pilot reported landing on a small road after the cockpit filled with smoke from an

electrical system problem.

ACN: 1423884 (49 of 50)

Synopsis A319 flight attendants reported being transported to the hospital after inhaling toxic fumes

in the cabin while on final approach.

ACN: 1423880 (50 of 50)

Synopsis A330 Flight Attendant reported throat irritation after noticing an acrid fume smell in the

galley in flight.

Report Narratives

ACN: 1441096 (1 of 50)

Time / Day

Date : 201704

Local Time Of Day : 1201-1800

Place

Locale Reference.Airport : ZZZ.Airport

State Reference : US

Environment

Light : Daylight

Aircraft

Reference : X

ATC / Advisory.Tower : ZZZ

Make Model Name : PC-12

Crew Size.Number Of Crew : 2

Operating Under FAR Part : Part 91

Flight Plan : IFR

Mission : Passenger

Nav In Use : FMS Or FMC

Nav In Use : GPS

Flight Phase : Climb

Airspace.Class D : ZZZ

Person

Reference : 1

Location Of Person.Aircraft : X

Location In Aircraft : Flight Deck

Function.Flight Crew : Captain

Function.Flight Crew : Pilot Flying

Qualification.Flight Crew : Air Transport Pilot (ATP)

ASRS Report Number.Accession Number : 1441096

Human Factors : Troubleshooting

Human Factors : Confusion

Human Factors : Distraction

Human Factors : Time Pressure

Human Factors : Workload

Analyst Callback : Attempted

Events

Anomaly.Aircraft Equipment Problem : Less Severe

Anomaly.Flight Deck / Cabin / Aircraft Event : Smoke / Fire / Fumes / Odor

Detector.Person : Flight Crew

When Detected : In-flight

Result.General : Maintenance Action

Result.Flight Crew : Returned To Departure Airport

Result.Flight Crew : Landed As Precaution

Assessments

Contributing Factors / Situations : Aircraft

Primary Problem : Aircraft

Narrative: 1

On initial climb we started to smell burning oil that got progressively stronger. No visible

smoke, smell seemed to be coming from the air conditioning vents. We continued climb,

brought flaps up, and switched to departure while attempting to determine the

source/cause. We decided to return, rather than proceed over water for extended period,

however departure frequency was too busy to notify. We switched back to tower and

notified them and we began turning back. Tower advised Departure and asked if we were

declaring an emergency. We did not declare and tower cleared us to land. We turned off

the air conditioning to rule it out, ran the approach check and set up a base leg. Odor

remained but was not as strong after power reduction for the turn back. Crew did not don

O2 mask; no visible smoke and fumes were not incapacitating. Did not pull air conditioning

shutoff as we were busy with configuring for landing. Ran before landing and prior to

landing checks and landed without incident. Still no visible smoke. Taxied to FBO, shut

down and upon opening the door, FO noticed same odor from left side forward, cowling

area. Two Ramp Agents also noticed same odor/smell. Opened forward left cowling no

visible signs of oil or abnormal conditions. Talked to maintenance, they pointed us to a few

different areas to inspect (both engine cowlings, Nose gear area, air conditioning and

generator air intake, oil cooler, separator, air intake, prop area, both mains, gear motor

area, aft equipment bay) however nothing abnormal detected. Approximately 15 minutes

later while in the area of the air stair, similar smell was detected by both crew members.

Synopsis

PC-12 Captain reported a burning oil odor with no visible smoke after takeoff. Unable to

determine the source, the crew returned to land.

ACN: 1441035 (2 of 50)

Time / Day

Date : 201704


Place



Altitude.MSL.Single Value : 25000

Environment

Flight Conditions : IMC

Light : Daylight

Aircraft

Reference : X

ATC / Advisory.Center : ZZZ

Aircraft Operator : Air Carrier

Make Model Name : EMB ERJ 145 ER/LR



Flight Plan : IFR

Mission : Passenger

Flight Phase : Cruise

Airspace.Class A : ZZZ

Person : 1

Reference : 1



Reporter Organization : Air Carrier


Function.Flight Crew : Pilot Not Flying



Human Factors : Situational Awareness

Human Factors : Training / Qualification


Person : 2

Reference : 2




Function.Flight Crew : First Officer





Events





Result.Flight Crew : Diverted

Result.Flight Crew : Landed in Emergency Condition

Result.Air Traffic Control : Provided Assistance

Assessments



Narrative: 1

While cruising at FL250 the flight deck crew as well the passengers and the FA in the cabin

noticed a strong burning odor. No smoke was present. The flight crew immediately donned

O2 masks and [advised] ATC. ZZZ was the nearest suitable airport and a decision was

made to divert there. CFR met the aircraft upon landing and did an exterior inspection of

the aircraft, no evidence of fire or smoke was visible to them. Aircraft then proceeded to

the gate and was deplaned. Maintenance arrived to investigate the cause.

Narrative: 2

Cruising at FL250 at 300 kts. We entered an area of IMC at cruise, Radar did not show any

precipitation in the area but we encountered light precipitation. After about 1 minute, the

comms started getting scratchy. The radar also started to show precip in all directions. I

associated this with the comms getting scratchy and suspected the aircraft wasn't

dissipating the static electricity well. I started to notice an odor. I couldn't put my finger

on the type of smell. It had a slight electrical smell but wasn't as pungent. I made a

comment to the CA and he confirmed that he smelled it as well. The CA called the FA and

she confirmed that she smelled it and a passenger had just asked her about the smell. I

suggested putting on O2 as a precaution, so we Donned masks. The CA called ATC and

requested a diversion to ZZZ. They issued a heading and descent to 18000. The CA further

communicated with the FA about looking for a source of the odor/smoke. Then messaged

dispatch and talked to the passengers that we were going to ZZZ. We received a clearance

to go direct to ZZZ and further descent instructions and prepared for an ILS. As we

departed the area of precipitation, the odor started to dissipate. I could still smell it at

18000. By the time we descended to 4000, the smell was completely gone. We

communicated our intentions with ATC that we would clear the runway and that we did not

see a reason to evacuate but requested CFR to walk around the aircraft as a precaution.

The landing was uneventful. We cleared the runway and contacted the Fire Supervisor and

coordinated a walk around with a heat gun and found no unusual heat signatures. The taxi

to gate was uneventful except our FOM page for ZZZ had an incorrect ops frequency.

When we confirmed that we all smelled an odor. I suggested O2 masks as a precaution.

We donned masks one at a time and confirmed communications. He [advised] ATC and as

requested ZZZ and a lower altitude. We were given a heading and 18000. I asked the CA

if we should do gear down and treat this as a rapid descent. He said no, so I used normal

procedures in the descent. The CA was communicating with the FA and the smell seemed

to be dissipating. The CA sent a message to company. I asked to run the QRH but couldn't

name a specific procedure. Since the odor was dissipating it wasn't clear which procedure

would be best. We definitely didn't have smoke confirmed from an electrical source but it

seemed like an electrical type odor. The QRH procedure for both air conditioning smoke

and electrical system fire or smoke seemed like they could make matters worse since the

odor was dissipating. Time was also an issue since we needed to prepare for arrival. We

received ATIS, reprogrammed the FMS and got landing numbers . I didn't want to delay

arrival to run procedures since the situation seemed under control.

There was confusion regarding the reprogramming of the FMS. I used the Direct button to

go direct to ZZZ but since it wasn't in the flight plan, it only gave us options for our

destination airport's approaches. I added ZZZ to the end of the flight plan and deleted the

arrival and approach into ZZZ1. Then the FMS allowed selection of the appropriate runway

and ILS. This was a distraction during a high workload situation. More training on

Diversions in the FMS would be helpful. This is not a commonly used procedure and the

rustiness showed.

Synopsis

EMB-145 flight crew reported they noticed a strong burning odor in the cabin and elected

to divert. The odor dissipated during descent.

ACN: 1438894 (3 of 50)

Time / Day

Date : 201704


Place



Environment

Light : Daylight

Aircraft

Reference : X

ATC / Advisory.TRACON : ZZZ


Make Model Name : A330



Flight Plan : IFR

Mission : Passenger


Airspace.Class B : ZZZ

Person

Reference : 1


Location In Aircraft : Cabin Jumpseat


Function.Flight Attendant : Flight Attendant (On Duty)

Qualification.Flight Attendant : Current


Human Factors : Physiological - Other

Events



Detector.Person : Flight Attendant


Result.General : None Reported / Taken

Assessments



Narrative: 1

When aircraft was climbing after takeoff I experienced a feeling of a stall. I mentioned it to

the flight attendant sitting across from me seconds after it occurred. Flight attendant

upfront called us and told us they smelled burning odors. I too smelled this and saw a

haze in the cabin. I put wet paper towels over my face until we landed.

Synopsis

A330 Flight Attendant reported smelling a burning odor and observed haze in the cabin

after takeoff.

ACN: 1438809 (4 of 50)

Time / Day

Date : 201704


Place




Environment

Light : Daylight

Aircraft

Reference : X



Make Model Name : Regional Jet 900 (CRJ900)



Mission : Passenger



Airspace.Class E : ZZZ

Person

Reference : 1











Events




Were Passengers Involved In Event : Y


Result.General : Physical Injury / Incapacitation



Result.Air Traffic Control : Issued New Clearance


Assessments


Contributing Factors / Situations : Human Factors


Narrative: 1

Aside from a few deferrals there was nothing unusual about the aircraft. We noticed a

slight electrical smell. Not unusual, as the avionics cooling fans sometimes make such a

smell. In the past when I mentioned that a cooling fan might be going bad, I was advised

that "we don't fix them until they quit working." I never argued, the cooling fans system

has enough redundancy. Also, if you smell something, after a while your sense of smell

acclimates to the smell and you no longer smell it even if it does not go away. The takeoff

and climb were uneventful. Sometime after 10,000 feet and before FL180, the electrical

smell we had smelled earlier on the ground became stronger. The smell was like the smell

of overheating bake lite. I asked my FO if she agreed that the smell was getting stronger

and she agreed. We called the flight attendants to ask if they smelled anything. One FA

said he was a smoker and it would be rare for him to smell anything. The other FA smelled

something, but nothing as strong as we described. As we climbed further, the smell got

stronger. I mentioned to my FO that I was getting a headache (I never get headaches).

She mentioned that her sinuses were really starting to bother her. We felt around the

cockpit, trying to find any "hot spots" in the cockpit, instrument panel, etc. We found

nothing unusual that could cause the smell. We thought for a minute and decided diverting

was a good idea.

I called on frequency, "Center, possible electrical smoke and fire in the cockpit. Nearest

suitable airport, ZZZ looks good." ATC said, "Cleared direct ZZZ, descend to (?) thousand

feet." I told my FO, "I am going on oxygen." I donned my mask. It was so filthy, I could

not see out of it to read the charts for ZZZ. I took the mask off and wiped the mask with a

napkin to no use. I looked for a wet-nap, but had just used my last one to clean the head

phones. I reached for my club soda and noticed I had not gotten one. I had more

important things to do so I would use the mask to grab a "whiff" of oxygen between tasks.

We sent an ACARS message to dispatch. My FO, sprang into action and got all needed

information for landing. ATIS, Landing Data, etc. SHE IS A GREAT FO AND DID A GREAT

JOB! We advised Flight Attendants and landing in ZZZ. No emergency action was needed

on their part, merely to expect that we were landing in ZZZ. My headache would come and

go between my whiffs of oxygen. We landed ZZZ without further event. The CFR infrared

scan showed no hot spots on the aircraft and we taxied to the gate as the smell subsided.

When we were greeted by the gate agent, she said that she noticed the smell the moment

she pulled up the jetway. Several passengers mentioned a smell as we deplaned. The local

mechanic mentioned that she could definitely smell what we had smelled when she

entered the cockpit. We did our damage control with passengers and, eventually, boarded

another aircraft and continued to our destination. When we got there, both my FO and I

mentioned some strange symptoms we were experiencing. We both mentioned that we

had some equilibrium problems. She said that she felt mildly drunk. I found that I had

bumped into things (bulkheads, door frames) that I should not have bumped into. I had a

low grade headache that persisted for a few hours, then went away. My FO mentioned that

her sinuses were bothering her still a day later. It seems that we were too busy with

taking care of passengers and then flight duties to stop and give any thought to the

possibility that the fumes we had inhaled might have been toxic and might have affected

us in some way. Just as a fatigued pilot can be too fatigued to know that he is fatigued, we

might, very well, have been too busy or impaired to realize that we were affected or we

just accepted that it might not have been that bad after all, when it actually was. I can

only speculate at this point. We would not fly another flight that day. A mild headache

persisted the next day. I chalked it off to hydration, food, stress, anything but toxic fumes.

Aside from being very busy, everything went smoothly, I credit a lot of that to a really

great first officer. I might check my oxygen mask a little more closely in the future, not

just test it and check for 100%.

Synopsis

CRJ-900 Captain reported fumes in the flight deck. They elected to divert to the nearest

suitable airport.

ACN: 1437931 (5 of 50)

Time / Day

Date : 201703


Place



Altitude.AGL.Single Value : 0

Aircraft

Reference : X




Flight Plan : IFR

Flight Phase : Parked

Person

Reference : 1


Location In Aircraft : Galley





Events


Anomaly.Flight Deck / Cabin / Aircraft Event : Illness



Were Passengers Involved In Event : N

When Detected : Pre-flight

Result.General : Flight Cancelled / Delayed


Assessments



Narrative: 1

Outbound crew noticed during their preflight duties an extremely potent smell near the aft

section of aircraft. Flight Attendant (FA) 1 was notified of the smell immediately. FA1

notified the Captain who then notified Maintenance. An inflight manager was also notified.

Air circulation on the aircraft caused the entire flight crew to become overwhelmed with

the fumes resulting in headaches, reddened eyes, coughing and breathing difficulties. The

Captain and the inflight manager ask the crew to leave the aircraft and return to the

boarding area. FA1 had extremely bloodshot eyes and requested medical attention. The

Captain filed a fume event report.

The flight was eventually canceled.

Synopsis

A330 Flight Attendant reported a potent smell in the aft section of the aircraft while

performing pre-flight duties. Eventually the entire crew was negatively affected by this

odor.

ACN: 1437899 (6 of 50)

Time / Day

Date : 201704


Place




Aircraft

Reference : X



Make Model Name : Large Transport



Flight Plan : IFR

Flight Phase : Taxi

Component

Aircraft Component : Turbine Engine

Aircraft Reference : X

Problem : Malfunctioning

Person

Reference : 1

Location Of Person : Company


Function.Dispatch : Dispatcher

Qualification.Dispatch : Dispatcher


Events

Anomaly.Aircraft Equipment Problem : Critical


Detector.Person : Air Traffic Control

When Detected : Taxi



Assessments



Narrative: 1

Crew called from their personal cell after landing that they had an emergency and were

currently sitting [on a taxiway]. Crew stated they had been informed by the FAA Tower

that they had smoke and possible fire coming from the Number 2 engine of the aircraft.

Crew stated Crash Fire Rescue was at the aircraft and that they had shut down the

Number 2 engine. Crew said they were fine, but asked that arrangements be made for the

aircraft to be towed to our ramp due they would not be able to move under their own

power. Crew also stated that they had ask CFR to stay with and follow the aircraft back to

our ramp.

Synopsis

Air Carrier Dispatcher reported he was advised by a wide body flight crew that they were

on a taxiway dealing with a possible engine fire that had been reported to them by the

Tower.

ACN: 1437845 (7 of 50)

Time / Day

Date : 201701


Place



Environment

Flight Conditions : VMC

Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger




Component

Aircraft Component : Engine Air


Person

Reference : 1









Events










Assessments



Narrative: 1

During climb out we noticed an odor in the cockpit that seemed to be like dirty socks or

wet carpet. We asked flight attendants if they could smell the same thing but they said no.

The captain went to the back of the aircraft to check. He could not smell it in the back.

When he returned we determined that the fumes were starting to have an effect on both

of us. We began running the fumes and smoke check list. We decided to divert to ZZZ. We

began using oxygen. We briefed cat 3 approach and ran over weight landing check list. By

this time in my opinion we both were becoming more and more incapacitated. Both of us

were having problems concentrating on the tasks at hand. We were given priority handling

by ATC and landed the aircraft without further problems. Emergency equipment met the

aircraft when we exited the runway. We were given instructions to taxi to the ramp. By

this time it seemed that we were nearly unable to follow instructions, but managed the

aircraft to a gate. Fire and rescue inspected the aircraft but didn't find anything wrong.

Synopsis

A319 flight crew reported fumes in the flight deck. After a short time they began to

experience problems concentrating and the onset of incapacitation.

ACN: 1437759 (8 of 50)

Time / Day

Date : 201704


Place

Locale Reference.Airport : ZZZZ.Airport

State Reference : FO


Environment


Aircraft

Reference : X

ATC / Advisory.Center : ZZZZ


Make Model Name : B777 Undifferentiated or Other Model



Flight Plan : IFR


Flight Phase : Initial Climb

Person : 1

Reference : 1





Function.Flight Crew : Relief Pilot


Experience.Flight Crew.Total : 15000

Experience.Flight Crew.Last 90 Days : 210

Experience.Flight Crew.Type : 11000


Person : 2

Reference : 2










Person : 3

Reference : 3











Person : 4

Reference : 4





Function.Flight Crew : Relief Pilot



Events




Were Passengers Involved In Event : N




Assessments



Narrative: 1

I was the working relief pilot. Shortly after gear was retracted, I saw and smelled an acrid

smoke. Seconds later, EICAS message, "Smoke detected crew rest F/D." Donned O2.

Called Flight Attendant at 1L with no answer. Later found out they couldn't hear the chime

over smoke alarm. Smoke seemed to dissipate a bit. Captain directed me to go to bunk

area to confirm issue. Smoke was in bunk room, smoke alarm at 1L, and smoke detected

alert on cabin alert panel. No fire witnessed just smoke seen and smelled.

Returned to cockpit donned mask as precaution once again. I coordinated the satcom call

with dispatch. Dispatcher was very difficult to understand. Very thick accent. Relayed

message that returning to [departure airport]... Asked for phone patch to [maintenance

control]. Relayed info to him and told him of the choice to land overweight. By this time

we are being vectored onto final. Landing uneventful; mindful of brake temps after

landing.

Narrative: 2

The First International Relief Officer (IRO) tried to contact the cabin crew and was unable

to reach anyone. The smell had almost completely dissipated but we could still hear the

alarm coming from the back. The IRO looked through the door and could see the lead

Fight Attendant standing in the hallway area. We decided to send her back into the cabin

to assess the situation since we could not speak to the Flight Attendants.

The second IRO was monitoring the communications in the cockpit and guarding the door.

The first IRO checked the bunk area and could not find any evidence of the source of smell

or faint hazy smoke.

Narrative: 3

The IRO was having difficulty communicating with the FA so the cockpit door was opened.

At that time I saw the smoke billowing as well as the alarms and flashing lights.

I worked with the Captain to determine whether we were going to dump fuel or execute an

immediate return to the field. We decided to return so I communicated that to Approach

Control and we received immediate vectors back for the ILS.

Narrative: 4

[Report narrative contained no additional information.]

Synopsis

B777 flight crew reported seeing and smelling acrid smoke accompanied by an EICAS

message regarding smoke detected in crew rest area after takeoff.

ACN: 1437680 (9 of 50)

Time / Day

Date : 201704


Place




Environment


Light : Night

Aircraft

Reference : X

ATC / Advisory.Ground : ZZZ

Aircraft Operator : Personal

Make Model Name : Super King Air 200



Flight Plan : IFR

Mission : Passenger

Flight Phase : Taxi

Route In Use : Direct

Component

Aircraft Component : Flap Control (Trailing & Leading Edge)


Problem : Improperly Operated

Person

Reference : 1



Reporter Organization : Personal

Function.Flight Crew : Single Pilot



Qualification.Flight Crew : Flight Instructor

Qualification.Flight Crew : Instrument

Qualification.Flight Crew : Flight Engineer

Qualification.Flight Crew : Multiengine


Events



Anomaly.Deviation - Procedural : Published Material / Policy




Result.Flight Crew : Returned To Gate

Assessments


Contributing Factors / Situations : Procedure

Primary Problem : Procedure

Narrative: 1

On taxi out to Runway XY we smelled a plastic burning smell. I also saw a little haze in the

cabin. I shut the air conditioning off (the bleed air was not on yet) and told Ground we had

a problem and wanted to return to the ramp. Shutting off the aircraft didn't help so I

decided to shut down the airplane and get everyone off. I told Ground I was shutting down

and requested assistance.

No one was injured and no sign of fire. The flap limit switch was set incorrectly and the

flap motor overheated.

Synopsis

BE20 pilot reported detecting a burning plastic smell on taxi. After shutdown, the odor was

attributed to an overheated flap motor.

ACN: 1437220 (10 of 50)

Time / Day

Date : 201703


Place




Environment


Light : Daylight

Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger

Nav In Use : GPS


Flight Phase : Descent


Person

Reference : 1









Events





Assessments



Narrative: 1

On initial climb, the Captain noted a very slight scent in the flight deck. I personally

couldn't tell anything different from standard. He noted shortly after (possibly through

transition) that the scent was no longer present. During cruise, we both reviewed the

smoke and fumes checklist in the QRH just in case anything further were to occur. Initial

descent was normal. Through approximately 15,000 MSL, the Captain noted the smell

once again, at this time, I certainly could smell the same scent. Although there was no

visible smoke/fumes, the smell was considerable. The flight attendants called prior to

sterile to advise us that the odor was very apparent in the cabin both forward and aft.

They likened it to a sock smell, but to me it didn't seem so. It's a difficult smell to explain,

certainly an acrid almost oily, plastic melting type of smell. We continued the approach to

a normal landing.

The APU was not running at the time of the event but was started during the after landing

checklist. Upon landing the smell was oppressively strong and continued to worsen during

the taxi and shut down. Once the aircraft shut down, we communicated again with the FAs

who were complaining of nausea. At this point, I had a strong headache and irritated

throat. Captain continued to feel worse upon shut down of the aircraft. Exterior walk

around didn't show anything that would suggest ingestion of anything that could have

caused an issue. All crew went to the emergency room for checks.

It's hard for me to suggest a fix other than to possibly run the aircraft and isolate specific

parts of the bleed system ideally in flight to get a true sense of what is happening and see

which area it is likely coming from.

Synopsis

A319 First Officer reported the entire flight and cabin crew felt physical effects from the

fumes and odor of unknown origin in the aircraft.

ACN: 1436838 (11 of 50)

Time / Day

Date : 201704


Environment


Light : Night

Aircraft

Reference : X





Flight Plan : IFR

Mission : Passenger




Component

Aircraft Component : Turbine Engine



Person

Reference : 1












Events









Result.Flight Crew : Took Evasive Action

Assessments


Contributing Factors / Situations : Company Policy



Narrative: 1

On the climb out we noticed a faint strange odor that neither of us had smelled before. It

was shortly after we had reconfigured the airplane at thrust reduction. We had used the

APU for takeoff due to the rain and having the extract P/B in the override position. It was

slightly sweet, and sort of like melted plastic. It was very brief and went away entirely. I

realized that it was the airplane that had had numerous fume events. Out of an abundance

of caution we reviewed the smoke/fumes procedures in the QRH. We continued on and

verified that the flight attendants had not smelled it. On the last portion of the descent we

started to smell it again. It started off very faint and didn't affect us especially. We both

focused on the final approach, as neither of us had ever been there.

After landing, we got a call from the flight attendants telling us that the A and C flight

attendants and first two rows of the cabin were smelling the fumes. We started the APU

and turned on the APU bleed to get a different bleed source. After we had parked at the

gate and opened the door we discussed what had happened with the flight attendants.

They started smelling the fumes just before I told them to take their seats for landing.

None of the passengers were still complaining about the smell and everyone seemed fine

overall. The First Officer (FO) and I both had a slight headache and our throats were a

little sore. We deplaned normally and started cleaning the airplane. I discussed the

situation with the flight attendants and the B said that she was starting to feel a strong

headache and sore throat. She had been on the airplane previously and had to go to an

urgent care center to get checked out. She wanted to go get checked out again.

Our C Flight Attendant (FA) also wanted to get checked out, especially because she is

pregnant. We all started feeling light headed, headaches, sore throats, and a couple of us

felt it in our lungs. I wrote it up in the logbook and called Maintenance. I turned off the

APU and we left the airplane quickly. I called the duty phone and explained the situation

and that at least three of us needed to get checked out. We all ended up going to the

Hospital where all of us were checked out. The medical staff noted inflamed throats, gave

the appropriate prescriptions and cleared us. We all returned the next day to do our

scheduled flight. All of us still had lingering symptoms of sore throats and I still do. I've

heard this aircraft has had numerous fume events ever since the #1 engine was

overhauled. The company/maintenance should be more aggressive with troubleshooting,

so that we don't get the same bad situation over and over. Once again only looking at the

bottom line, has put many crews and passengers in harms way. In hindsight, we could

have completed the smoke/fumes checklist at the gate, but I don't believe it would have

had much impact, as everyone had already been exposed to the fumes. Because it went

away quickly in the climb, we assumed it would be short-lived during the descent. We

weren't aware it was in the cabin right away and where it was coming from.

Synopsis

An A319 Captain reported detecting a faint, strange, sweet odor during after takeoff and

again during approach. Both pilots and two flight attendants reported being light headed

with headaches and sore throats for which they received medical attention. Number one

engine had recently been overhauled.

ACN: 1436565 (12 of 50)

Time / Day

Date : 201702


Place

Locale Reference.ATC Facility : ZOB.ARTCC

State Reference : OH


Aircraft

Reference : X







Component

Aircraft Component : Pneumatic System



Person

Reference : 1










Events







Result.Aircraft : Equipment Problem Dissipated

Assessments



Narrative: 1

The captain and I smelled oil fumes (gym sock smell) climbing out. We went on oxygen.

Around 18,000 feet the smell dissipated so we took the masks off. The smell came back on

the descent so we went back on oxygen again.

I was scheduled to split off the trip in ZZZ so I went home. I developed a bad headache

within a couple hours, had very red eyes, and had severe fatigue over the next few days.

It's now 31 days later and although the bad headache abated, I've had a dull headache

every day since this happened. Excedrin and Advil don't help. I've never had a headache

last this long although I have had headaches after fume events in the past.

[Suggest] proper maintenance of engine or APU bleed air source.

Synopsis

A330 First Officer reported smelling oil fumes in the flight deck. A few hours after the flight

he reported severe fatigue and a headache that has lasted 31 days.

ACN: 1435935 (13 of 50)

Time / Day

Date : 201703


Place




Environment

Light : Daylight

Aircraft

Reference : X



Make Model Name : B737-800



Flight Plan : IFR

Mission : Passenger

Flight Phase : Taxi

Component

Aircraft Component : Air Conditioning and Pressurization Pack



Person : 1

Reference : 1








Person : 2

Reference : 2








Events








Result.Flight Crew : Returned To Gate

Assessments



Narrative: 1

After engine start and during taxi both the Captain and First Officer smelled a strong odor

of dirty socks in the cockpit. We started to feel light headed and nauseous. I donned my

oxygen mask. I checked with the flight attendants and they did not smell anything. We

returned to the gate. We went to the hospital.

Narrative: 2

After push back and normal start of #2 engine, ground crew disconnected and CA

instructed me to start #1. Engine #1 started normally. After start/taxi checks completed

and the takeoff checklist initiated, we received taxi instructions, and began to roll. That's

when I first recognized an unpleasant odor and made a comment to the CA. We continued

taxi for another minute or two and the CA asked me if I smelled dirty socks. I replied yes,

and the CA decided to return the gate, we coordinated with Ground to return and the CA

put his O2 mask on. I elected to open the FO side window as we were still fairly close to

terminal and wanted better communications. We elected to start the APU and turn off

Engine Bleed air. We returned to a different gate than we departed from in another

terminal after coordination with Ops. We didn't feel as well as we had previously, both

pilots experiencing some nausea and headache. We notified station personnel and they

helped coordinate our transport to the hospital for further evaluation.

Synopsis

B737 flight crew reported a dirty sock smell after beginning to taxi for takeoff. The flight

returned to the gate and the pilots were transported to a hospital.

ACN: 1435678 (14 of 50)

Time / Day

Date : 201703

Place



Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger



Component




Person

Reference : 1





Function.Flight Attendant : Flight Attendant In Charge



Events










Assessments



Narrative: 1

Twenty seconds after takeoff the B flight attendant in the AFT galley called and informed

me they were smelling a distinct "dirty sock" smell that they believed to be toxic fumes. I

then called the captain, informing them of what the B flight attendant had just told me.

The captain said he would call right back. About a minute later the odor had made its way

through to the plane and was present in the front galley where it made me light headed

and dizzy with a slight headache. The odor was noticeable to the passengers. I called the

AFT galley back and they had told me they had donned oxygen. The captain soon called

me back and told me we were heading back, that it would not be an emergency landing,

and he would make the announcement to the passengers and we should prepare the cabin

for landing. At this time said they could also smell the odor. We returned the gate where

the AFT doors were disarmed and opened due to the discomfort the B/C flight attendants

were experiencing. Burning eyes/skin/metal taste/dizziness. The paramedics were called

to the aircraft and the flight crew decided to go to the hospital to be checked out and have

their blood tested.

Synopsis

A320 Flight Attendant reported a "dirty sock" smell in the rear of the aircraft shortly after

takeoff. The Captain was informed and the flight returned to the departure airport.

ACN: 1435356 (15 of 50)

Time / Day

Date : 201703


Place




Environment


Aircraft

Reference : X





Flight Plan : IFR

Mission : Cargo / Freight

Flight Phase : Takeoff

Component

Aircraft Component : Pneumatic Ducting


Problem : Failed

Person : 1

Reference : 1








Person : 2

Reference : 2







Events





Result.Flight Crew : Rejected Takeoff

Assessments



Narrative: 1

Max power takeoff with APU running. At 80 knots, an aural alert sounded and the red FIRE

CARGO AFT annunciation appeared on the EICAS. We were accelerating quickly, and with

my reaction time, I took control of the airplane and rejected the takeoff at approximately

95 knots. I did not use heavy braking because I wanted to expedite clearing the runway.

As we slowed to a safe taxi speed, we accomplished the FIRE CARGO AFT checklist, which

resulted in discharging halon agent into the lower aft cargo compartment. As we brought

the airplane to a stop at the intersection of F and T3 as directed by Tower, the FIRE

CARGO AFT annunciation remained displayed. Therefore, I decided to run the evacuation

checklist and deployed the escape slide at L1. Crew successfully evacuated via the left

slide without injury. Additionally, we noticed the presence of pneumatics-related cautions

on the EICAS, but I felt it would be a waste of time to address those. However, we did

include that information in the [Maintenance] debrief a short time later over the phone.

Fire rescue crews were on scene quickly, but the language barrier was difficult. Eventually,

someone who spoke some English arrived and we were able to communicate somewhat.

Eventually, the fire chief and maintenance were able to determine there was no fire, and

the fire personnel left. After phone discussions with [Maintenance], and investigation, it

was determined that a pneumatic duct failed, which caused excessive heat in the lower aft

cargo compartment, which triggered the fire warning.

Narrative: 2


Synopsis

B777-200 flight crew reported they aborted a takeoff and evacuated the aircraft due to a

FIRE CARGO AFT annunciation. Post flight inspection determined a pneumatic duct had

failed.

ACN: 1434798 (16 of 50)

Time / Day

Date : 201703


Place




Environment

Flight Conditions : Marginal

Light : Daylight

Aircraft

Reference : X





Flight Plan : IFR

Mission : Passenger



Person

Reference : 1








Human Factors : Communication Breakdown

Communication Breakdown.Party1 : Flight Crew

Communication Breakdown.Party2 : Other

Communication Breakdown.Party2 : Maintenance

Events







When Detected : Aircraft In Service At Gate


Assessments



Narrative: 1

Prior to our departure from ZZZ, we had almost completed the boarding process when the

flight attendant stated that something did not smell quite right towards the rear of the

aircraft and that it smelled as though there was an electrical odor such as overheating

wires or insulation. I had the first officer go check it out and they came back with a

confirmation that the flight attendant was indeed correct and that there was something

amiss with the aircraft. I then calmly instructed the flight attendant to instruct the

passengers to calmly collect their belongings and to exit the aircraft and head back to the

gate area as we were unfortunately on a mechanical delay being very careful not to cause

alarm or confusion. After this was completed maintenance came on the aircraft and began

to track down the source. After a fair amount of time maintenance found what they

believed to be the source and dealt with it accordingly. The odor still remained so I started

the APU, opened the baggage door and then closed the main and galley service door with

the PACKs on and the RECIRC Fan off to try and clear the air in the cabin of the odor. After

five to ten minutes the odor was no longer present. Having been informed by maintenance

that there were no available aircraft to swap into and being reasonably satisfied with the

corrective actions taken, we boarded up the passengers again and departed. The flight

was normal until about twenty-five to thirty minutes into the flight I estimate when I

noticed that my eyes were irritated and starting to burn and my throat was starting to feel

scratchy. I asked the first officer if he felt the same and he stated that his throat was a bit

irritated however as he wore contacts his eyes were probably not being as affected as

mine were. I looked to see if there was any visible smoke on the flight deck and did not

notice any. I called the flight attendant to ask her if her eyes were burning or her throat

was bothering her and she stated that she was feeling the same symptoms that I was. I

turned off the RECIRC Fan again and elected to continue to [destination] as that was our

closest airport. Seeing as there was no visible smoke, I did not [advise ATC]. After we

landed and taxied to the gate, as the passengers were getting off, a few of them made

comments about their eyes burning and that a few had started coughing from an irritated

throat. These were mainly communicated to the flight attendant who relayed the

information to myself.

Threats specifically related to this event include but are not limited to, the mechanical

condition of the aircraft. There was a reported electrical issue that created an odor with no

smoke that was dealt with however not fully investigated in my opinion. From the time

that maintenance started tracking the problem until the issue was "resolved" by local

maintenance was less than thirty minutes. The lack of an available or suitable aircraft to

swap out also lead to operational pressures to accept the current aircraft and it should be

noted that for a very brief period of time, less than five minutes I would guess we had

been swapped into a different airplane however as soon as maintenance control got word

from local maintenance that the problem had been addressed we were again placed back

in Aircraft X to operate the flight as originally planned.

I believe that the company needs to adopt a more stringent and formal policy when it

comes to dealing with any issues reported by crews that deal with smoke/odor/irritants

such as the event described above. An electrical issue can sit there and fester or smolder

for hours or even days before it reaches the point of no return and while I believe that the

electrical issue first reported and the subsequent odorless irritant that we experienced in

flight are not related, more time to properly diagnose, trouble shoot and address these

issues would have been better in the long run for everyone from the crew, the passengers

and even the company as a whole as this resulted in an aircraft being stranded at an out

station. Once we had landed and I made the initial contact with maintenance control, I

explained everything in detail as well as my detailed write up to the maintenance

controller however, the communication between the various desk/departments was

severely lacking to almost nonexistent in my opinion as I was receiving calls from various

desks and people who had either no information about what had happened or was

happening or had incorrect information about what had happened. I received a call two

hours after we landed where I was accused of not relaying information that passengers

had been affected as they thought that only the flight deck had experienced a smoke

issue. First, there was no visible smoke period during that entire event and secondly I had

communicated to maintenance control when I described the issue that not only had the

crew been affected but that passengers had been affected as well and let it be known as

such. There was more miscommunication as well between the company and the two pilots

who were tasked with flying a recovery flight to bring an empty airplane over to get us and

our passengers. They were told that the reason for the flight was that there was an issue

with one of the pilots seat and while there was a deferred item on the first officer's seat on

Aircraft X, that was clearly not the reason for the events that transpired. This

misinformation could have been dangerous to those pilots had they been tasked with

flying Aircraft X as originally planned until I timed out for the day forcing these pilots to fly

the flight back. Miscommunication in general is a hazard that I have encountered more

than I care to admit to over the last few years here when it was never that way when I

first got hired and this is a big issue that I would say is more important to address than

the condition of the fleet.

Synopsis

EMB145 Captain reported that during flight there was an electrical odor such as

overheating wires or insulation.

ACN: 1434100 (17 of 50)

Time / Day

Date : 201703


Place



Environment


Weather Elements / Visibility : Turbulence

Weather Elements / Visibility : Thunderstorm

Aircraft

Reference : X



Make Model Name : Dash 8-300



Flight Plan : IFR

Mission : Passenger




Component

Aircraft Component : Powerplant Fire/Overheat Warning



Person : 1

Reference : 1








Person : 2

Reference : 2








Events








Assessments



Narrative: 1

Shortly after rotation Engine Fire Detect Warning light illuminated as well as Fault B lights

on both engines. Flight crew decided to [advise ATC] and return to field to land.

Emergency vehicles were available if their assistance would be needed and they were not

needed. Landing and taxi was under normal procedures. Passengers were informed to

remain seated and we returned to gate. After deplaning, maintenance came out to the

aircraft and checked the systems and MELd the appropriate systems and the flight

continued.

A return to field event occurred coinciding with an emergency.

Narrative: 2


Synopsis

Dash 8 flight crew reported returning to departure airport after the Engine Fire Detect

warning light illuminated.

ACN: 1434081 (18 of 50)

Time / Day

Date : 201703


Place



Environment


Light : Daylight

Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger



Person

Reference : 1








Events



Detector.Automation : Aircraft Other Automation





Assessments



Narrative: 1

Right after takeoff as the gear was coming up in the flight deck we got a master warning

for lavatory smoke. We [continued on our route] to clean up the aircraft and to reach a

safe altitude as in the aviate, navigate, communicate. At this point I was able to smell a

burning electrical smell from the flight deck as well. We called the flight attendant, who

confirmed the smell as well did the passengers in 1A and 2A. The flight attendant went to

the lavatory and saw no fire in the lavatory or cargo area. At this point I started to run the

QRH for lavatory smoke. On the way back to the front of the aircraft the flight attendant

reset the lavatory smoke system which cleared the message for us up front. Around the

same time the electrical burning smell started to go away in the flight deck so we never

declared an emergency and told ATC we needed to return for an electrical smell. I finished

the QRH procedures and then went on to get landing data for the overweight landing

including telling dispatch what was going on as well as calling operations on the radio for a

new gate. On short final and on the runway landing roll I started to get short whiffs of the

burning smell again, we taxied to the gate with no further issue.

Synopsis

EMB-145 First Officer reported returning to the departure airport after noticing an

electrical smell and receiving a master warning for lavatory smoke.

ACN: 1434014 (19 of 50)

Time / Day

Date : 201703


Place

Locale Reference.ATC Facility : ZZZ.Tower



Environment


Light : Daylight

Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger



Person

Reference : 1











Events







Assessments



Narrative: 1

Immediately after liftoff got a SMOKE CREW REST F/D EICAS as well as a master caution.

Smoke alarms were heard going off in cabin as well. Flight Attendant confirmed they also

had smoke in cabin. We also had a thin mist of smoke in cockpit. All 3 of us up front

donned O2 masks and stabilized the aircraft. Decision was made to return to [the

departure airport]. Landed overweight.

Synopsis

B777 crew reported returning to the departure airport shortly after takeoff due to fire

detection and smoke alarms with visible smoke on the flight deck and cabin.

ACN: 1433712 (20 of 50)

Time / Day

Date : 201703


Place




Environment

Light : Daylight

Aircraft

Reference : X





Flight Plan : IFR

Mission : Passenger


Person : 1

Reference : 1









Person : 2

Reference : 2










Events




Detector.Person : Gate Agent / CSR



Assessments



Primary Problem : Human Factors

Narrative: 1

During preflight checks Maintenance was troubleshooting an inoperative APU. We just

started boarding when the rear Provisioning Agent working the rear galley yelled, "APU

fire" to one of the Flight attendants. The rear Flight Attendants, along with a Deadheading

Captain ran to the flight deck to tell the Mechanic about the APU fire. The Mechanic shut

down the APU and pulled the fire switch and then ran to the back of the aircraft to assess

what was going on with the APU.

As the Mechanic left the cockpit, the First Officer discharged the APU Fire Bottle. There

was no Fire Warning bell or any other fire indication in the flight deck. Apparently there

was some residual fuel in the APU because of previous failed start attempts and that

created the appearance of a fire when the mechanic successfully started the APU. After the

event Maintenance deferred the APU Fire Suppression System and returned the aircraft to

service with the deferred items.

Narrative: 2


Synopsis

B737 flight crew reported discharging the APU fire bottle when residual fuel from a failed

start created the appearance of a fire during the APU start.

ACN: 1433693 (21 of 50)

Time / Day

Date : 201703


Place




Environment


Light : Night

Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger




Component

Aircraft Component : Cargo Compartment Fire/Overheat Warning



Person

Reference : 1









Events






Assessments



Narrative: 1

On the Arrival, the Flight Crew experienced an aft cargo fire indication. We complied with

the QRH, [advised ATC] and determined the nearest suitable airport, evaluating altitude,

distance, flying time, weather, and airport facilities. We diverted to the nearest suitable

airport. We notified Dispatch through ATC and ACARS and communicated with the Flight

Attendants and Passengers. After landing, we stopped the aircraft on the runway and set

the parking brake. We communicated to the Flight Attendants and Passengers to "remain

seated and wait for further instructions."

We started the APU and shut down both engines. We established communications with Fire

and Rescue, and informed them of an aft cargo fire indication and let them know that it

was clear to approach the aircraft. Fire and rescue inspected the aircraft and found no fire

or heat damage and later communicated that everything was "all clear." Next, we

communicated with the Flight Attendants and Passengers that the Emergency Personnel

had not found any damage to the aircraft and that we would be safely starting engines and

taxiing to the gate. Upon arrival at the gate, asked the Passengers to remain seated while

we figured out the next course of action. One fire truck met the aircraft at the gate to

confirm no damage in the aft cargo bin. I called Dispatch and Maintenance.

Operations had limited Operations Personnel on duty and were not able to stay with the

aircraft and give us personalized attention. At this point the Operations Control was trying

to figure out the next course of action. At first, Company Maintenance and Dispatch

discussed having Contract Maintenance clear and sign-off the aircraft and for us to

continue. I expressed that this was not a plan that worked for me, nor for our Passengers.

This is where I asked to speak to the Chief Pilot on Call. Chief Pilot on Call agreed with my

assessment. By this time, the First Officer was approaching duty time limitations and

would not be legal to continue flying; however, he remained on board to assist with the

Passenger's wellbeing and to answer any questions or concerns.

The next plan was to find another First Officer and move the passengers to another

aircraft to continue to ZZZ. I spoke to the Flight Attendants and asked how they were

doing and if they were ok to continue to ZZZ. Everyone was reluctantly willing to continue

at this point. As we waited, I evaluated my personal fitness for duty and chose not to

continue flying, notifying the Chief Pilot on Call. While coordinating the next course of

action, the aft cargo fire alarm sounded again inadvertently. We had all Passengers and

Crew calmly and orderly evacuate the aircraft into the jetway with their belongings. The

cargo bin was inspected by the Flight Crew and no smoke or fire was observed. After

tracking down an Agent, the Passengers were cleared from the jetway to the terminal to

wait for further assistance. At this point the Flight Attendants chose not to continue flying

duties with my full and complete support! The entire Crew was released from duty and

provided a hotel room near the airport.

Note: this aircraft was MELed by a prior Crew for the Cargo Fire Suppression System (MEL

26-19-XX). This MEL was reviewed and complied with prior to flight. This was the second

leg of the day on this aircraft for the Flight Crew. Also, we had four commuting Flight

Attendants on board that were flying to ZZZ to be in position for work the next day. They

also found themselves in the middle of a stressful situation.

There are several lessons learned and things I would have done different after looking

back at the event.

1. In communicating with the Flight Attendants, I would have used the phrase "prepare

the cabin for arrival". I did communicate the appropriate information for our situation;

however, "prepare the cabin for arrival" is a standard phrase that conveys what is

expected.

2. In hindsight, after arriving at the gate, I would have had the Passengers exit the

aircraft to the terminal while we determined the next course of action. I would have done

this before making a call to Dispatch and Maintenance. Unfortunately, I found myself on

the phone longer than anticipated and in a situation where the Agent was busy with other

flights. In spite of this, the First Officer and Flight Attendants did a very nice job of

keeping the Passengers calm, informed, and taken care of.

3. We needed to have an Agent or another Company representative stay with the aircraft

at the gate the entire time on the ground. I understand some stations are small and have

limited staffing; however, in events like these it makes it very difficult to receive the

support needed for the Crew and Passengers.

4. If I had to do it over again, I would have gotten the Chief Pilot on Call involved in the

conversation from the start when I first called Dispatch and spoke to Maintenance. This

possibly could have prevented spending time looking at options that did not make sense

under the circumstances.

Synopsis

B737 Captain reported a diversion due to an aft cargo fire indication. The cargo bin was

inspected and no smoke nor fire was observed.

ACN: 1433441 (22 of 50)

Time / Day

Date : 201703


Place




Environment


Light : Daylight

Aircraft

Reference : X





Flight Plan : IFR

Mission : Passenger


Component

Aircraft Component : Drinkable/Waste Water Syst



Person : 1

Reference : 1









Person : 2

Reference : 2










Events





Result.General : Evacuated


Assessments




Narrative: 1

After completing the parking checklist the aft flight attendant noticed a smell of smoke

coming from the aft portion of the cabin. After checking it out the captain asked me to

contact ground control to get the fire trucks rolling to the aircraft. He also asked me to

contact operations to get maintenance out to the aircraft. After accomplishing those two

things I stayed at the front of the aircraft and kept the cleaning crew and catering from

entering the aircraft. After the fire department declared all clear we handed the aircraft

over to maintenance.

Narrative: 2

We had a normal flight up until just after finishing parking checklist. As we were packing

our bags, the aft FA called saying there was a smoke smell in aft cabin. We had just put on

ground power and shutdown APU which will matter later in description. I talked with the

FA to determine source of smell. We thought that maybe it was coming from brakes since

aft cabin door was open, or air conditioning system and it would dissipate soon since APU

had just been shut down. We could not see or smell any indication of smoke in first 3/4 of

aircraft so I called operations and I directed my FO to call ground to send fire personnel to

our aircraft.

I then started working my way to aft of aircraft since the aft FA had already started

announcing over PA for remaining passengers to leave everything and exit aircraft

immediately. A mechanic showed up at that point and we continued to rear of plane but

could not smell or see any smoke. Once we reached around 5 rows from rear of plane I

could smell smoke and as we went further we could see the smoke. Fire personnel soon

showed up and we were trying to determine source of smoke which was dissipating.

The plane was empty of passengers at that point so mechanic put the APU back on as we

tried to find source. That completely cleared smell. The smell was strongest 3 rows from

rear when it happened according to the FA. I remembered that prior to departure there

was no water pressure in entire aircraft. Maintenance repaired issue and signed off write

up and we received new release. Apparently the only system that is below the 3rd row

toward rear of cabin is the water system compressor which only works when there is no

pneumatic air pressure from APU or engines. Once we switched to ground power and

shutdown APU, the water compressor started and apparently began to smoke. It stopped

again when Maintenance turned APU back on as we tried to investigate source of smoke.

All in all a little confusing but we worked together as a team and everyone was safe.

Synopsis

B737 flight crew was informed by a Flight Attendant that there was smoke in the aft cabin

after gate arrival. The problem was traced to a faulty potable water system compressor.

ACN: 1433294 (23 of 50)

Time / Day

Date : 201703


Place




Environment


Weather Elements / Visibility.Visibility : 10

Light : Daylight

Aircraft

Reference : X

ATC / Advisory.CTAF : ZZZ



Make Model Name : Skyhawk 172/Cutlass 172



Mission : Training

Flight Phase : Initial Approach


Airspace.Class D : ZZZ

Component

Aircraft Component : Engine Exhaust System



Person

Reference : 1




Function.Flight Crew : Instructor


Qualification.Flight Crew : Commercial








Events








Assessments




Narrative: 1

Exhaust gas leak on board while conducting a biannual flight review. Upon entering left

midfield downwind, I noticed a smell of exhaust fumes in the cockpit and requested right

turn out direct to ZZZ. Tower approved this turn out and we headed direct to ZZZ at 2500

feet. Upon reaching 2500 both pilot and I (instructor) began feeling symptoms of carbon

monoxide poisoning. We slowed the aircraft down momentarily to open the windows to get

additional fresh air into the cockpit. We then proceeded to close the windows so we could

get our speed up to land back at ZZZ for a straight in approach. We requested all other

traffic in the area to heed us so we could arrive with no delay and everyone flying at ZZZ

made sure to stay clear and help us arrive as quickly as possible. I did not officially declare

an emergency with ATC as it was more vital to communicate my intentions with the traffic

currently flying at ZZZ which proved to be a huge help to us; however I should have

declared an emergency with the other tower and landed there as soon as I smelled the

exhaust rather than try to make it back to ZZZ.

Synopsis

C172 instructor pilot reported detecting exhaust fumes while in the traffic pattern and

elected to depart the pattern and return to home base.

ACN: 1433144 (24 of 50)

Time / Day

Date : 201703


Place




Environment

Light : Daylight

Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger



Person

Reference : 1











Events


Anomaly.Deviation - Speed : All Types






Result.Flight Crew : Became Reoriented

Assessments




Narrative: 1

I received a 4 chime call from our Number 1 Flight Attendant. In a panicky voice, I was

informed that there was fire and smoke in the cabin, and that we need to land

immediately.

We advised ATC and started our divert. During our descent, My First Officer suggested that

we add the drag to help get the descent going as I started to slow through 265 as we were

approaching 10000 ft. I thought we were fine. As we continued coordination with ATC,

AARF, and Flight Attendants - I then decided that the gear would be a good option. I was

hand flying and proceeding directly to the outer marker. I glanced at the airspeed and

thought I saw 265 again and called for gear down, My First Officer put gear down as he

was saying verified. And then said not verified and immediately put the handle back up.

The gear never moved. Just the handle. I was around 285. So either I misread the

airspeed and thought I was at 265. Or I was at 265 and pushed the nose over while hand

flying and called gear down and airspeed crept up quickly. The correction was so swift that

I quickly dismissed it. The rest of divert went well.

Nothing I would change as I thought I saw the correct gear speed. If anything, slow a little

bit down. Pressed a little [more] than other emergencies due to it was smoke in the cabin

and hearing the panic in the flight attendant voice.

Synopsis

B737-800 Captain reported the landing gear lever was moved to the down position at a

speed higher than authorized during a rapid descent.

ACN: 1433099 (25 of 50)

Time / Day

Date : 201703


Place



Environment


Light : Daylight

Aircraft

Reference : X



Make Model Name : EMB ERJ 170/175 ER/LR



Flight Plan : IFR

Mission : Passenger

Nav In Use : GPS




Person : 1

Reference : 1









Person : 2

Reference : 2








Events


Anomaly.Flight Deck / Cabin / Aircraft Event : Passenger Electronic Device

Detector.Person : Passenger



Result.Flight Crew : FLC complied w / Automation / Advisory


Assessments

Contributing Factors / Situations : Equipment / Tooling

Primary Problem : Equipment / Tooling

Narrative: 1

FA reported that a first class passenger reported to them that his portable battery was

heating up and smelled like burning plastic. FA put the battery in a container with water as

per their procedure and notified us that they had done that and there was no irregularities

at this time. We advised them to carry on with their procedures and monitor the battery.

Advised dispatch of the situation as well.

Looking into if this particular type of battery pack is good for flight.

Make: Uniden

Model: WM4807

Narrative: 2


Synopsis

EMB-175 flight crew reported a passenger's portable battery overheated so the Flight

Attendant placed the battery in a water container as per company procedure.

ACN: 1432636 (26 of 50)

Time / Day

Date : 201703


Place




Environment


Weather Elements / Visibility : Rain


Light : Dawn

Ceiling.Single Value : 800

Aircraft

Reference : X


Aircraft Operator : Corporate

Make Model Name : Beechjet 400



Flight Plan : IFR

Mission : Passenger


Route In Use : None

Component

Aircraft Component : Electrical Wiring & Connectors



Person

Reference : 1



Reporter Organization : Corporate










Analyst Callback : Completed

Events








Result.Aircraft : Aircraft Damaged

Assessments



Narrative: 1

Shortly after starting the Number 2 Engine we had a large amp draw. Battery feeder fail

master warning occurred and we promptly shut down both engines. Cabin door was

opened and line guy said he saw smoke coming from our tail section. We evacuated the

cabin and nobody was injured. Fire was electrical in nature due to Metal-Oxide-

Semiconductor Field-Effect Transistor (MOSFET) box failure and was contained mostly

internal aft of the baggage compartment, however visible fire damage to the deice boot

section of the right elevator. I was made aware after the incident (by the mechanics at the

repair station) that an optional service bulletin was available and not complied with by

choice of the owner. Apparently there have been a few fires on type because of this exact

component failure.

Callback: 1

The reporter stated that about 15 seconds after engine start they received a feeder fault

and that the load meter for Number 2 generator went to the max indication. The generator

tripped off line as a result of the excessive load. The reporter also stated that the cause of

the smoke was the power supply for the stabilizer deicing boot shorted out causing a fire

in the tail section of the fuselage. The reporter stated that this box should not be powered

during ground operations, only in flight when deicing is required. The reporter stated that

the fire changed the color of the metal surrounding the area of the fire. The reporter also

stated that if this happens in flight the only option is to pull the control breaker for that

system. The reporter also stated this option does not put the fire out, only removes power

from that component.

The reported stated that this has happened at least four times on other BE400s. The

reporter stated that there is an optional Serviceable Bulletin for this problem, but there are

no replacement parts available.

Synopsis

BE-400 Captain reported that they received a "Battery feeder fail" master warning due to

an electrical fire in the tail section.

ACN: 1432106 (27 of 50)

Time / Day

Date : 201703


Place




Environment


Light : Night

Aircraft

Reference : X


Aircraft Operator : Air Taxi

Make Model Name : Beechjet 400



Flight Plan : IFR

Mission : Passenger




Component

Aircraft Component : Electrical Power


Problem : Failed

Person

Reference : 1



Reporter Organization : Air Taxi










Events



Detector.Automation : Aircraft Other Automation




Result.Flight Crew : Executed Go Around / Missed Approach




Result.Aircraft : Aircraft Damaged

Assessments



Narrative: 1

We had just taken off and climbing through 11,500 ft I saw the FMS1 warning light on the

PDF flashing red. I looked down to see both FMS's with GPS position lost on them. I looked

up to see both PDF's an ND's go blank. Shortly after that the cockpit went dark with only a

faint glow from the standby instruments. We only had the number 1 radio for a time than

we lost it. I had asked my First Officer to instruct departure control that we were returning

and he asked us if we needed assistance and gave me direct and 2000 ft. I instructed my

First Officer to tell him to roll the emergency equipment. As I slowed the aircraft down the

trim became extremely heavy because the trim had failed at 275 kts and I was now below

160 kts to lower the landing gear. Before turning final I called for the gear to be extended.

At that point we only got one red unsafe light and one main gear light. I turned final in

hopes that the gear would come down but they did not. I had to do a missed approach and

go around. On the go I told my First Officer to do an emergency gear extension. I had all I

could to maintain aircraft control at this point and it was quit difficult for my First Officer to

reach across me to lower the gear. We finally got three green lights and I turned to final.

We had no flaps, speed brakes, or thrust reversers to stop the aircraft. I told my First

Officer to prepare to stop the aircraft with the emergency brake system when we touched

down. I cut off the power over the overrun and the aircraft slammed onto the runway.

Both mains blew after the emergency brakes were applied and we started drifting for the

left edge of the runway. With much difficulty I managed to stop the aircraft close to the

center of the runway about 700 ft from the end. After stopping, I instructed my First

Officer to get the passengers off the aircraft as I ran the shutdown checklist. I soon

followed and discovered that the left main gear was on fire so I put the fire out with the

fire extinguisher. NO ONE WAS HURT. My First Officer did a wonderful job and without him

the outcome could have been a lot different. All this happened from startup to engine

shutdown in just 3 tenths of an hour, we did not have a lot of time.

Callback: 1

The reporter stated that a definitive cause of the electrical anomalies was not found but

several electrical components along with both starter generators were replaced. The

aircraft has since flown with no anomalies noted.

Synopsis

BE400 Captain reported a complete electrical failure shortly after takeoff, rendering PFD's,

trim, landing gear and flaps inoperative. Emergency gear extension was used to lower the

landing gear and emergency brakes used to stop the aircraft.

ACN: 1431799 (28 of 50)

Time / Day

Date : 201702


Place




Aircraft

Reference : X





Flight Plan : IFR

Mission : Passenger


Person : 1

Reference : 1


Location In Aircraft : General Seating Area







Person : 2

Reference : 2









Events





Result.Flight Crew : Overcame Equipment Problem

Assessments



Narrative: 1

After takeoff there was a strong odor in the cabin, stronger in back galley. I was still

buckled in my jump seat. I saw the A and B flight attendants get out of their jump seats

and move into the cabin. The odor was strong and I could feel a burning in my chest that

went away in half hour or so. The crew decided that everyone was capable of going on to

[destination]. During flight the C flight attendant had to take oxygen and several others

had headaches.

Narrative: 2

While sitting in jump seat Flight Attendant B smelled nauseous fumes immediately during

takeoff and landing [at our destination]. Once air born, the pilots performed an air

cleaning procedure, which eliminated the fumes until landing. Also, once air born,

passengers commented about the nauseous fumes. Fortunately, no passengers reported

any physical or medical reactions from the fumes to me. Flight Attendant C needed oxygen

for 20 minutes or so. She continued to perform her duties afterwards.

Synopsis

The flight attendants on an Airbus A330 reported that there was a very strong odor in the

cabin after takeoff.

ACN: 1431757 (29 of 50)

Time / Day

Date : 201703


Place

Locale Reference.ATC Facility : ZZZZ.ARTCC


Environment


Aircraft

Reference : X

ATC / Advisory.Center : ZZZZ





Flight Plan : IFR

Mission : Passenger


Component




Person : 1

Reference : 1







Person : 2

Reference : 2







Events








Assessments



Narrative: 1

During climb, Flight Attendant called and stated strong odor in aft cabin. Odor was like a

dirty sock pack smell mixed with a metallic and slightly acidic smell. Sent IRO back to

check and verify. It dissipated and then the smell was noticed by Flight Attendant again,

IRO again went aft to check and confirmed slight smell. Smell noted in cockpit. Just after

his return, Lead Flight Attendant called again and reported strong smell in First Class with

a "haze". Made decision to return to [departure airport], [advised ATC], donned O2 per

QRH Smoke/Fumes Procedure and turned [back] direct. Contacted company. Made

OVERWEIGHT landing using QRH procedure. Had Emergency Personnel accompany aircraft

to gate.

Odor and fumes in aircraft. Find and fix source of fumes and odors. Providing for dedicated

Fumes (not Smoke) QRH procedure would help and address specific area. Educate Pilots

and Flight Attendants for fumes in aircraft.

Narrative: 2


Synopsis

A330 flight crew reported returning to departure airport after "dirty socks" fumes were

reported in the cabin.

ACN: 1431443 (30 of 50)

Time / Day

Date : 201703

Place


Aircraft

Reference : X





Flight Plan : IFR

Mission : Passenger

Flight Phase : Taxi

Component

Aircraft Component : APU Pneumatic System & Ducting



Person

Reference : 1



Cabin Activity : Deplaning





Events








Assessments



Narrative: 1

On taxi in and deplaning process cabin filled with strong exhaust electrical burning smell.

We deplaned everyone and quickly got off the plane ourselves. Experienced choking,

coughing, nickel taste, headaches and eye and throat irritation. Mechanics stated they

might have found a 2 inch hole in the APU pack.

Synopsis

A321 Flight Attendant reported smoke and fumes in the cabin and experienced illness after

the event.

ACN: 1430620 (31 of 50)

Time / Day

Date : 201703

Place




Environment


Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger


Flight Phase : Taxi


Person : 1

Reference : 1



Cabin Activity : Boarding

Cabin Activity : Deplaning





Person : 2

Reference : 2









Events





Assessments



Narrative: 1

Just as we were cleared for takeoff making final turn onto runway, I smelled a strong

burn-off or fuel smell. I heard a few of the passengers (pax) sitting forward of wing area

(rows 14-16) say their throat was burning. I had a pilot from another airline sitting in front

of me and asked his opinion. He said he felt that it was residual burn-off. With the position

we were in, I made the decision that it was unsafe to contact the pilots at that critical

phase of take-off. Shortly after we took off the odor began to dissipate. I waited until we

were out of 10,000 feet and had received bells from Capt. I asked other Flight Attendants

(FA) if anyone else smelled anything. Forward cabin was okay and the #2 FA smelled

nothing in the aft cabin. The #4 FA said she smelled a little something, but was not

concerned at the time. I called Capt and asked if I could go in flight deck and speak with

him. He took the situation very seriously and wanted to know and be kept informed if the

odor returned. He also wanted the other FAs take on the issue. He said he would return to

[departure airport]. Everyone else had agreed that the odor had gone away, including the

pax sitting in the affected rows where it was strongest prior to take-off. The decision was

made to continue on with the flight. Nothing else was detected during the flight. After

landing and on taxi -in, I started noticing the odor returning. When we parked aircraft and

doors were opened, the odor became unbearably strong. It was worse than before and

was choking me and burning my eyes and throat. As soon as last pax deplaned, I walked

out to top of deplaning stairs to get fresh air. We advised Capt what was taking place. The

Capt instructed us to close aft deplaning door as the odor was stronger in the back of

aircraft at that point but was quickly getting just as strong throughout aircraft and in the

forward galley/cabin. At that point we all stood outside of the aircraft. It was decided after

a short time that we should get our bags and get off aircraft entirely.

[Suggestion:] more thorough maintenance checks.

Narrative: 2

During Taxi in to gate and prior to gate arrival, FAs and pax noticed strong fume odor in

cabin. FAs complained of eye and throat irritation. I noticed odor in cockpit after pax

deplaning. Contract Maintenance could not duplicate problem. I elected to have

[Company] Maintenance look at aircraft before agreeing to fly aircraft. Maintenance

arrived some hours later to troubleshoot issue.

Maintenance indicated to me that a "significant" hole was found in the low pressure duct.

It would be helpful to have an absolute protocol in place for these events. I have never

been (and will never be) comfortable relying on contract Maintenance to deal with fume

issues.

Synopsis

A321 Flight Attendant and Captain reported smelling a strong burn-off or fuel smell during

takeoff, then once again after landing.

ACN: 1430618 (32 of 50)

Time / Day

Date : 201703

Place




Aircraft

Reference : X



Flight Plan : IFR

Mission : Passenger


Flight Phase : Taxi

Component




Person : 1

Reference : 1








Person : 2

Reference : 2









Person : 3

Reference : 3









Person : 4

Reference : 4









Events







Assessments




Primary Problem : Ambiguous

Narrative: 1

Two fume events occurred on board. One before boarding, which was reported to the flight

deck. The second occurred after passengers where on board. The strong smell was mainly

in the aft. The Flight Attendants (B&C) in the aft were most affected and the FAs forward

of the aircraft experienced slight symptoms. As a result, the crew was taken to the

hospital for treatment. All passengers where removed from aircraft.

Narrative: 2

All four FAs were on the aircraft doing their preflight checks. A strong odor came through

the cabin, smelled like chemicals and dirty socks to me. We notified the First Officer (FO)

because the captain was not on aircraft. FO felt it was jet fuel from an aircraft that just

pushed off the gate. The odor went away. We began boarding. Just as boarding was

complete. I and another FA were towards the back of the aircraft I was in the galley a

horribly strong odor the same as the one we experienced earlier was very present in the

back of the cabin but stronger than the first. I called the lead FA and he told the captain.

Within minutes we both had headaches, nausea, and visible shakes. Mechanics came on

the airplane looked around the galley. We told them our experience. They returned to the

cockpit. The captain made an announcement that the passengers would have to deplane

that this aircraft was going to the hangar due to a problem with the ventilation and air

conditioning system on the aircraft. He told passengers that they were getting another

plane. I had called the crew service center to tell them we just had what we believe is a

fume incident on the aircraft and asked for a supervisor to please come to the airplane.

Several supervisors came and assisted us in getting a ride to the hospital where we all had

blood work done to test for carbon monoxide (they really didn't know what toxins to test

for) and we were all put on IV fluids and oxygen. I was also given zophran for my nausea,

since I was very sick to my stomach and had vomited on the airplane before I left the

plane. I personally felt like I was in a fog, my memory was jarred and my motor skills

were not sharp. I couldn't even get the [gown] on at the hospital, I needed assistance

from a nurse. Several hours later we were all discharged from the hospital. The supervisor

was waiting in the hospital waiting room and arranged a ride for all of us back to the

airport.

These FUME events need to be recognized as a problem that has been going on way to

long and it is crazy that they are still happening. The passengers don't realize they could

be exposed to hazardous toxins. We as FAs are aware of the problem.

This is my first known fume event and the odor was something I have never smelled

before. The symptoms were something I had never experienced on the airplane before.

Airlines, including mine, need to take recognition that there is a problem with toxic fumes

and helping the people that suffer from the exposure instead of the company turning their

heads and ignoring their employees that something really is wrong and causing these toxic

fumes. Trust me if [the CEO] or his family were involved in a fume event and got sick or

disabled from the exposure maybe something finally would be done to stop them and quit

ignoring and denying employees. When on the job and exposed to toxins and having to be

removed from the job and out of work, and being told that this will not be an [issue] is a

disgrace!

Narrative: 3


Narrative: 4


Synopsis

Four B757 flight attendants reported two fume events at the gate prior to push back. After

the second event the flight attendants were taken to the hospital and the aircraft was

taken out of service.

ACN: 1430527 (33 of 50)

Time / Day

Date : 201701

Place




Aircraft

Reference : X




Flight Plan : IFR

Mission : Passenger




Person : 1

Reference : 1



Cabin Activity : Service





Person : 2

Reference : 2








Person : 3

Reference : 3








Person : 4

Reference : 4








Events






Assessments



Narrative: 1

Old musty sock odor in cabin upon takeoff. All Flight Attendants (FA) contacted one

another and captain, flight deck smelled it also, dissipated somewhat and returned,

diversion was decided against and just get into [destination]. Landed just before midnight.

FA had headaches and nausea and wanted checked out by medical personnel. Station

Manager did not meet aircraft as asked, daily ops took 2 1/2 hours to get us medics. Was

transported to hospital by ambulance for blood tests and blood was not drawn till [very

early morning]. Tests ok by that point, released from hospital to follow up with physician.

Was transported to airport for deadhead.

Take care of aircraft and ground them if they have these problems until solved as to not

put crew and passengers' health and lives in jeopardy. If it does occur, take care of crew

IMMEDIATELY. Transport to hospital IMMEDIATELY for testing and treatment as to not

expose them to chemicals and fumes as short of time as possible. Each station NEEDS to

be aware of these situations and how to handle them!

Narrative: 2

During takeoff for this flight there was a weird smell throughout the cabin one of the flight

attendants in the rear of the aircraft called the A-FA and notified her of the strong odor.

The A-FA called the flight deck and informed them of the odor. A few minutes later the

captain called and stated that we would be diverting. Then a few minutes later the captain

notified the lead FA that we were going to continue on to [original destination]. As we

continued on the fumes in the cabin continued and were getting stronger. There were also

a few passengers complaining about the smell. All the while we were doing service and

also trying to answer passengers' questions, keep calm and stay professional without

causing panic. After finally landing in ZZZ we requested medical attention and also

requested to have a manager meet us at the gate, which never happened. Instead we

waited outside for an hour and a half before we were told to go to the other side of the

terminal where the manager would be waiting for us. We wait another 30-40 mins before

the fire department medical team shows up, they take our vitals and personal information.

We then get transported by ambulance to a local hospital for further evaluation.

We spend all night in the ER and finally get discharged [early the next morning].

Narrative: 3


Narrative: 4


Synopsis

The flight attendants of an Airbus A330 reported a musty sock odor in the cabin during

takeoff and continued during flight. Many required medical attention.

ACN: 1430524 (34 of 50)

Time / Day

Date : 201611

Place



Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger


Flight Phase : Landing

Flight Phase : Final Approach


Person

Reference : 1







Events






Assessments



Narrative: 1

Upon descent and final walk through a strong odor was noticed around row 12 and aft. I

immediately asked a coworker to verify the odor and immediately called the captain. The

captain informed me that we were 2 minutes from landing and we would check it on the

ground. The odor was reminiscent of paint thinner and caused an immediate severe

headache. One we landed, the smell disappeared for the majority but remained noticeable

around the 3L/3R doors. Myself and one other Flight attendant became ill and required

medical attention for nausea, headache, dizziness, and body shakiness. We were

transported to a hospital via ambulance.

The captain requested maintenance and they found an unidentified orange fluid around the

aft air pack.

Synopsis

A321 Flight Attendant reported a strong odor in the cabin during cruise resulting in

physically ill symptoms.

ACN: 1430484 (35 of 50)

Time / Day

Date : 201606


Place




Environment

Light : Daylight

Aircraft

Reference : X





Flight Plan : IFR

Mission : Passenger


Person : 1

Reference : 1










Communication Breakdown.Party1 : Flight Attendant


Person : 2

Reference : 2












Person : 3

Reference : 3












Person : 4

Reference : 4












Events












Assessments


Contributing Factors / Situations : Company Policy



Narrative: 1

When we got to the gate the plane was late inbound. When we got on the plane the agent

wanted to board right away. I checked with the Captain and he said we had mechanics on

board. The mechanics said not to board. The agent boarded anyway. We had lots of issues

with this plane. Inflight Entertainment (IFE) did not work a latch in the back was totally

gone and some cockpit issues plus the APU did not work so it was very hot on the plane.

We closed the 2L and armed our doors. Then the Captain said the mechanics needed to

get back on so we disarmed all doors. We reopened the 2L door to let the mechanics back

on for an issue in the cockpit. I was in the 1L lav when I smelled a burning electrical odor.

Before I could open the door (about 2 seconds) the lav was full of smoke. I heard

someone say smoke in the cockpit, smoke in the cockpit. When I looked to the right I

could not see past row 2 because of the whitish yellowish smoke. The smoke was burning

my eyes and throat. I turned to my left to tell the Captain (I could not get to the cockpit

because 2 mechanics and an agent were in the door) when I heard evacuate over the P.A.

The Business class passengers were already up and moving to the 2L door. The D FA and I

got our passengers out the 2L door and helped with the flow of passengers while yelling

our commands. I was at the door with the E and we had the passengers going out side by

side for faster flow. The F started to stop passengers and take their bags from them I said

let them go it's faster. You need to go to your exit, she did not go. I saw a lot of

passengers with their roll-aboards. Then I heard over the PA, stop the evacuation. I turned

and ran to the cockpit (the D is arriving at the same time). I tell the Captain that the

passengers cannot breath and the smoke is thick. I get on the PA and say continue the

evacuation. The Captain says someone has blown a slide and for me to go back and see

where it is. I run to the back down the aircraft left aisle. About 30 passengers are left on

the plane and they are trying to get their luggage out of the overhead bins even though

we are yelling get out leave everything. I see the 3L door is open with no slide and a

passengers and her 2 children are looking out the door (3L) and trying to decide if they

should jump. I point and tell them to go to the boarding door and I put the strap across

the door. I can see 3R is open with a slide inflated and the G is with passengers at that

door. 4L and 4R have slides inflated and the C and B are with their respective door. I tell

the FA's to check the cabin and lavs behind me and make sure everyone is off and for

them to get off the plane. I tell the Captain that we have 3 slides inflated and all the

passengers are off. The firemen board at this time and they want all crew off except the A

and the cockpit. The FAs get off onto the jetway and the F tells them not to go to the gate

area because the company will not pay you if you get off the plane. I tell them to go to the

gate area now.

I ask if everyone is ok. The K says she needs oxygen and I put her on oxygen from the

plane. I get her to the gate area and get her bags for her and then I go back and talk to

the firemen. They send us all to the gate area and the paramedics check everyone out.

One FA has high blood pressure and another has asthma problems. We are all coughing

and have burning itchy eyes. I am on the phone with the company most of the time that

we are in the gate area. About 4 hours I am told. I check on my crew and I am working to

get us transportation to the hospital then to the hotel. The agent is a tremendous help

with a bus, paramedics extra. I check on a few passengers that are in the gate area. We

go to the hospital and we are there about 5 hours or so getting blood work. We have no

chairs to sit on and end up on the floor. They take the K first because she has Lupus and

then checkout the C with the high blood pressure and then the F then the rest of us. [The]

agent puts drinks and food on her own credit card because we have not had anything

since we left the hotel. We get back to the hotel. We get to our rooms and meet back in 45

minutes to eat and see if we have been released from duty yet.

The Captain tells us the [someone] might want to talk to us and not to have any alcohol

because we are not released from duty yet. When I meet back in the restaurant a few of

the FAs are having a drink. I said the Captain and I have told you not to drink. I was told

they can do what they want after such a hard day. Long argument and they continued to

drink. The Captain came in and told them the same thing and again they refused to listen.

I am going to the front desk for phone calls because I do not have international calling and

my battery is low. The F keeps taking the phone from me to talk to [the company]. I am

having to argue with her to get my phone calls. She wanted to be in charge and that really

made my job harder and I missed some important information. No one in the company

seemed to know that I was A FA. I finally [had a meeting about the event] in the hotel.

Just gave him the basics about what I saw. At midnight I went back to the restaurant and

had a few bites of my cold food.

I tried to get the FAs to tell me what flight they wanted to take home. All I got was

argument. I told them they could go when they felt comfortable to leave. I was trying to

set up their flights home. The [investigators] wanted to talk to the ones that had deployed

the slides so they had to stay. I chose the first flight the next day. Six of us went on the

early flight. We were listed as non-revenue instead of deadheading so the agent would not

give us a boarding card because we did not check in 24 hours ahead. More stress. Finally

get our seats and get on the plane home.

The pressure to board has gotten ridiculous and unsafe. Getting the plane off the gate at

all cost is not safe. Boarding and on time is more important than safety. We have to have

the entire crew briefings back. Our CRM is so important. Most briefings from the cockpit

(sometimes not the Captain) consist of air time and maybe a weather report. The biggest

issue for this flight was pressure to board and get off the gate.

Narrative: 2

I was standing in the galley between 2L & 2R. Flight Attendant (FA) said, "Smoke!"

Suddenly noticed smoke at the ceiling near 2R. I looked down the aisle and smoke filled

the cabin in less than 3 seconds. FA "H" was standing near 2R. I said, "We have to call the

Captain and evacuate!" I reached for the phone at 2R. I called the Captain and there was

no answer. I pressed the PA button and announced, "Evacuate, Evacuate!" The smoke was

still there and there was a smell of an electrical fire. We proceeded to evacuate. The

Captain came on over the PA and said, "Stop the evacuation." I'm not sure at this point if I

got back on the PA or just said out loud, "We need to keep evacuating!" The Captain did

not see the smoke or smell the fumes so I just kept on evacuating. I think at some point I

did hear the Captain come back on and say, "Evacuate!" We continued the evacuation until

all the passengers were off.

This might be a lesson that if the mechanics are on and say, "We are not ready to board",

perhaps the Operations Manager, should respect that and not board until they are ready. I

remember she and I had a bit of a disagreement about the boarding. She pressured the

front mechanic to board until he finally said yes. The mechanic in the back did not want to

board. I clearly told her that and she said, "I will deal with that later." I'm not sure if that

would have made a difference in the event but it did seem rushed to board them and then

the passengers sat on the airplane another hour until we actually closed the door the first

time.

Narrative: 3

[Report narrative contained no additional information]

Narrative: 4

[Report narrative contained no additional information]

Synopsis

A330 flight attendants reported an aircraft evacuation at the gate due to heavy smoke in

the passenger cabin.

ACN: 1430480 (36 of 50)

Time / Day

Date : 201610


Aircraft

Reference : X





Flight Plan : IFR

Mission : Passenger



Person

Reference : 1








Events






Assessments



Narrative: 1

I smelt odd fumes for about twenty to thirty minutes and also after confirming the smell

with the other working flight attendants, after the "B" flight attendant reported the odor to

the flight deck, I reported it also. The odd fume went away about thirty minutes after

reporting the issue to the captain. In the last hour of the flight I started feeling abnormal.

I had a pounding headache, felt dizzy, fatigue and weakness in the legs, my stomach

becoming tight and upset, I felt shortness in breath and chest pain, and it felt like day two

of a very bad "flu-like" bug in less than an hour. I immediately reported the issue to the

captain, and when we landed I called crew service center about the issue, and discussed

the injury with my flight service manager. Due to this injury I could not perform my core

duties, specifically evacuations or announcements. I confirmed the same symptoms with

my flight attendant crew members and we went to the emergency room for immediate

treatment at the hospital.

Based on what happened to me and the test results I feel this is chemical fume injury in

carbon fume family, specifically carbon monoxide. Carbon monoxide is a by-product of the

incomplete combustion of carbon-containing materials. Aviation fuel contains carbon and is

a ready source of carbon monoxide when burned. Carbon monoxide is truly a hidden

menace because by itself, it is both a colorless and odorless gas. An individual would not

be aware of its presence until symptoms developed, or during treatment it was determined

exposure had occurred. The least desirable situation would be incapacitation. The true

problem comes when exposure is so gradual that you don't perceive it. We perceived

fume, reported the issue, and are now injured.

Synopsis

A320 Flight Attendant reported that cabin fumes became unbearable during the flight,

resulting in illness.

ACN: 1430444 (37 of 50)

Time / Day

Date : 201701

Place


Aircraft

Reference : X



Mission : Passenger


Person

Reference : 1









Events








Assessments



Narrative: 1

About 10 minutes into boarding Captain called me into flight deck to confirm odor from

fumes. Strong odor was detected in flight deck as well as in back section of cabin. Most

passengers were commenting and held things to their noses. Captain immediately

requested boarding to cease and all passengers with carry bags and crew to deplane.

Two Flight Attendants (FA) experienced headaches, another felt funny and I had

continuous coughing. Other FA symptoms remained for a while, my coughing started up

again when I re-entered aircraft an hour later to retrieve my bags.

Synopsis

A321 Flight Attendant reported a strong odor in the aircraft during boarding. When many

passengers and cabin crew members began to feel ill, the Captain decided to have the

passengers exit the aircraft.

ACN: 1430346 (38 of 50)

Time / Day

Date : 201701


Place



Environment


Light : Daylight

Aircraft

Reference : X





Flight Plan : IFR

Mission : Passenger


Person : 1

Reference : 1








Person : 2

Reference : 2








Person : 3

Reference : 3








Events







Assessments



Narrative: 1

During take-off a gust of fumes entered the entire cabin. I asked [the crew] who also

experienced the same odor. [Another FA] notified flight deck. Flight deck advised returning

to the [departure airport].

Narrative: 2


Narrative: 3


Synopsis

Cabin crew reported strong fumes in the cabin after application of take off power, that

resulted in a return to the departure airport.

ACN: 1430291 (39 of 50)

Time / Day

Date : 201611

Place



Aircraft

Reference : X





Mission : Passenger


Maintenance Status.Maintenance Type : Unscheduled Maintenance

Maintenance Status.Maintenance Items Involved : Repair

Component

Aircraft Component : Fuel System



Person

Reference : 1








Events









Assessments



Narrative: 1

Before we even left, we had a fuel leak. It was eventually fixed and we departed for ZZZ.

On the climb I smelled an odor, but I figured it was from the repair and it wasn't too bad.

We were all strapped into our jump seats (I was at the 3L) on the descent into ZZZ when

a very strong odor was detected. It smelled like a combination of deicing fluid and dirty

locker room odor. It was so strong I had to breathe into my sleeve and I looked over at

the other Flight Attendant sitting at the 3R jumpseat and she was doing the same thing.

My eyes began to sting as well as my throat. Several passengers asked me what the smell

was and I literally couldn't answer them because I began to cough.

The passenger right in front of me put her sweater over her nose and mouth. All

passengers deplaned and the crew gathered at the front as we discussed what had just

occurred. Flight Services were called and [someone] met us to take us to the Airport

Urgent Care Facility for employees. We filled out paperwork and I was brought to the back

where they weighed me, took my height measurements, looked into my eyes, throat,

ears, and nose, and took my blood pressure. I told her my eyes were still stinging and my

throat burned, along with a headache. She gave me Advil, Benadryl for my throat, and 5

vials of eye drops. I ask her if she was going to draw my blood and she was puzzled by it.

I then went back out to the waiting room [and was] informed if we wanted our blood

tested, we would have to go to the hospital. I declined because it had already been

[several] hours of all of this and I felt like it had been a waste of time. No one seemed to

know what the protocol was to deal with this event.

Synopsis

A330 Flight Attendant reported an odd odor in the cabin that resulted in physical

symptoms related to the odor.

ACN: 1430284 (40 of 50)

Time / Day

Date : 201701

Place



Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger


Airspace.Class C : ZZZ

Person : 1

Reference : 1







Person : 2

Reference : 2







Person : 3

Reference : 3







Person : 4

Reference : 4







Person : 5

Reference : 5







Events





Assessments



Narrative: 1

Upon descending... during final cabin prep for landing. I was made aware of a smell in the

back of aircraft. It began to travel forward to the front of aircraft. Not only did Flight

Attendants (FA) smell that strange smell (dirty sock)... passengers asked as well: "What is

the strange smell. We are instructed to report such to flight deck. So everyone said... go

report to flight deck and we will finish walk through. We all felt strange. The flight deck

said they smell it too.

My head started hurting and my eyes felt strange... my chest had a little pain and a little

daze. The [other Flight Attendants] tasted something metallic in their mouths and throats.

After landing I did my arrival procedures... Verified, stand by for all call ...some of the

Flight Attendants sounded weird... sluggish. I felt strange as well. Start feeling less light

headed when were on the jet way.

I don't understand how to eliminate fumes. The pilot said once they smelled it they put on

their oxygen mask. I believe we should be train to apply oxygen to ourselves so... we

need nothing to affect our ability to respond. As stated the [other Flight Attendants]

sounded weird or sluggish on PA. So we should have put of portable oxygen mask as well

when a fume incident occurs.

Narrative: 2

15-20 minutes before landing we had strong cabin odor/fume that all 4 Flight Attendants

(FA) smelled at the same time and never smelled before. A FA contacted Captain to

complain of odor. The F FA said passenger in front of her seat noticed smell also. Felt

pressure on my chest during descent. After landing felt very light headed, disoriented and

shaky after deplaning. Paramedics met flight and did vitals. Whole crew went to the

hospital upon Captains suggestion. I had EKG, chest x-ray, arterial draw testing for

neurotoxins and blood pressure. My blood pressure was 188/98 and 185/92 which is very

high for me. Never had blood pressure issues. Concerned for my health for chemicals in

uniforms and toxic fumes from job. My carbon monoxide level was 5 which they

questioned. The smell on aircraft was very strong and different from anything I have ever

smelled. To me the smell was like very stale musty air.

Narrative: 3


Narrative: 4


Narrative: 5


Synopsis

A321 Flight Attendant crew reported a strange odor on the aircraft during descent, all crew

members affected and went to the hospital. Lead Flight Attendant recommended that they

should also be trained to use portable oxygen during fume events.

ACN: 1430267 (41 of 50)

Time / Day

Date : 201607

Place




Environment

Light : Daylight

Aircraft

Reference : X





Flight Plan : IFR

Mission : Passenger

Flight Phase : Taxi

Component

Aircraft Component : Hydraulic System



Person : 1

Reference : 1










Person : 2

Reference : 2




Function.Flight Attendant : Off Duty




Person : 3

Reference : 3








Events



Anomaly.Deviation - Procedural : Maintenance

Anomaly.Ground Event / Encounter : Other / Unknown




Assessments




Narrative: 1

Prior to boarding, we were under maintenance due to a possible hydraulic leak. The

mechanics noticed the fluid on the ground, had the flight deck run pressure checks and

then later gave us clearance to operate within 15 minutes. Myself, nor the B & C FAs felt

safe operating the flight with knowing that there was a (major) hydraulic leak. The captain

said that maintenance gave the ok saying we were good to go. I was worried that the AC

wasn't properly evaluated while under maintenance and that if the flight deck spoke up

more, this incident could've possibly been prevented.

Just as the captain announced: Flight Attendant (FA) prepare for take-off, there was a

LOUD shrieking noise followed by a very strong fume odor. I notified the flight deck and

made an announcement to the passengers. The captain initiated an evacuation of the

aircraft. At that point, it was too late to do a full cycle of evacuation commands because

the passengers were already in the galley ready to exit the aircraft. I used my hand to

hold them back and commenced with come this way, leave everything.

As a suggestion, I would recommend that the commands be amended to incorporate the

old commands of stand back until the slides fully deploy.

I also don't know the recommendation for this, but we need to be sure that passengers

are willing to stay at the bottom of the slide to help people off and away from the aircraft.

The majority of passengers ran away in fear. At least, two times I found myself asking

more people to help at the bottom.

Narrative: 2


Narrative: 3


Synopsis

A320 cabin crew reported a failure in the hydraulic system while taxiing resulted in smoke

in the cabin and a subsequent call by the Captain to evacuate.

ACN: 1427425 (42 of 50)

Time / Day

Date : 201702


Place

Locale Reference.ATC Facility : ZZZ.TRACON



Environment


Light : Daylight

Aircraft

Reference : X



Make Model Name : PA-23-250 Aztec



Flight Plan : IFR

Mission : Passenger




Component

Aircraft Component : Attitude Indicator(Gyro/Horizon/ADI)


Problem : Failed

Person

Reference : 1












Events



Anomaly.Deviation - Altitude : Overshoot

Anomaly.Deviation - Procedural : Clearance



Assessments



Primary Problem : Human Factors

Narrative: 1

Departed and cleared to 2,000 expecting 7,000, I got distracted when my gyro CB popped

with a strong smell of electrical wiring and flew through 2,000 to 3,000 and when

Departure saw my error, he told me to maintain 3,000. I am too dependent on my

autopilot/Flight Director (FD) and when it all failed, I got distracted, again!

Synopsis

PA-23-250 pilot reported he climbed through his ATC assigned altitude when his gyro CB

popped.

ACN: 1426678 (43 of 50)

Time / Day

Date : 201702


Place




Aircraft

Reference : X





Flight Plan : IFR

Mission : Passenger


Component

Aircraft Component : APU



Person

Reference : 1








Events





When Detected : Pre-flight


Assessments




Narrative: 1

Just after taking our seats in [the cockpit] the aircraft lost electrical power. I looked at the

overhead and noted that ground power was available and selected it on. (I presumed a

bad ground power connection at first.) As my eyes passed across the overhead panel I

noted and the First Officer verbalized a fault light on the APU master switch. Shortly

thereafter, we got an APU AUTOSHUTDOWN ECAM. We followed ECAM procedures and

contacted Maintenance. The APU was put on MEL and during that process, we noted a

green flashing low APU [oil]. We pointed it out to the mechanic, but thought little of it at

the time.

After shutting down at our destination, the first flight attendant, informed us that on two

of the previous three legs prior to ours, there had been fumes in the cabin that were so

strong that passengers were covering their mouths and noses in an attempt to avoid the

smell. He said he reported the fumes to the Captains in both cases, but that the Captains

did nothing about it.

Note that we nor the passengers or cabin crew detected any odors during our flight.

We contacted Maintenance and explained the situation. I was asked to and did enter a

write up in the Aircraft Maintenance Log (AML) and complete an aircraft cabin odor report

as best as I could. (Since I was not on the flights where it occurred, I was unable to

answer most of the questions on the report.)

Maintenance showed up to the aircraft promptly after my call and found that the APU had

been leaking oil and it appeared it had run down the skin of the aircraft and reentered at

the APU intake.

I was later informed that when Maintenance started the APU after my write up, "flames

shot from the back of the APU because the oil leak was so large."

This event occurred because the APU leaked oil and although the flight attendants made

the problem known to the prior flight crew, they did not report it to maintenance.

While, I'm not in a position to speculate how the first fumes in the cabin encounter could

have been avoided, it seems from what I was told that had the first Captain to be notified

of the issue made a logbook entry, notified maintenance, and filled an aircraft cabin odor

report, the subsequent problems could have been avoided.

Synopsis

A319 Captain reported an APU auto shut down at the gate due to low oil quantity. The APU

was deferred, but later, Maintenance determined that leaking oil likely caused fumes in the

cabin on previous legs with a different crew.

ACN: 1426650 (44 of 50)

Time / Day

Date : 201702


Place

Locale Reference.ATC Facility : ZZZ.ARTCC



Environment


Light : Daylight

Aircraft

Reference : X



Make Model Name : Citation Excel (C560XL)



Flight Plan : IFR

Mission : Passenger




Component

Aircraft Component : Electrical Wiring & Connectors


Problem : Failed


Person : 1

Reference : 1













Person : 2

Reference : 2













Events



Anomaly.Conflict : Airborne Conflict







Result.Flight Crew : FLC complied w / Automation / Advisory


Assessments


Contributing Factors / Situations : Chart Or Publication




Narrative: 1

While acting as Pilot in Command on a flight we smelled an electrical burning smell

followed by smoke in the cockpit. We were on the RNAV arrival around 12000 ft. We

executed an emergency descent to ZZZ airport to land. I was the flying pilot in the left

seat while First Officer handled the radios and checklist items. During the emergency

descent we encountered a TCAS RA and complied with it by climbing and turning to our

right towards the north to avoid the VFR aircraft which was not talking to approach.

Approach did advise us of the aircraft since it was on radar. After complying with the RA

we continued with the emergency descent and checklist items prior to landing. We

commenced and complied with the Electrical Fire or Smoke checklist from the CE-560XLS

checklist. Once the checklist directed us to place the cabin master and generators to the

off position the smoke subsided but the electrical burning smell was still present. I decided

to deploy the passenger oxygen masks manually due to the continuing burning electrical

smell. We briefed the passengers of the situation and advised them of our plans to

immediately land. We landed and cleared runway and performed an evacuation of the

aircraft on the taxiway due to the existing electrical burning smell. The landing was normal

and uneventful. We immediately disconnected the ship's battery after exiting the aircraft.

Fire and airport ops met us at the aircraft. Fire performed a search on the aircraft and

advised us that there was no present danger. We had the aircraft [towed] to the ramp.

The crew and passengers suffered no injuries or problems from the event.

Overall I feel as though the First Officer and I acted appropriately and worked well

together as a crew under the circumstances we were dealing with. There are a lot of things

going through your mind when you smell burning and see smoke in an airplane. Our goal

was to get the plane on the ground as soon as possible. I would advise all crew members

to pay close attention to the TCAS before initiating an emergency descent to avoid any

conflicts with other aircraft like we had. I was focused on getting the airplane on the

ground and [the First Officer] was focused on the checklist and radios. The TCAS system

definitely helped to prevent a conflict with the VFR aircraft. Following the appropriate

checklist lead to the turning off of several important switches which eventually put an end

to the smoke. We both have learned positive things from this event and come out of this

as better pilots in my mind.

Narrative: 2

The XLS electrical fire/smoke checklist is complicated. To be honest it is not a well-

organized checklist, nor is it laid out in a way that guarantees that a crew can perform the

checklist error free in a stressful emergency situation. Ideally the right seat pilot needs to

be Pilot Flying (PF), so that the left seat pilot can read and execute the checklist items

since most of the items are on the front left cockpit panel. I believe in this case it was

good idea for PIC to remain PF in left seat, and perform the checklist items as I called

them out with my confirmation for critical items. By remaining PM, it allowed me to be

methodical with the checklist from the right seat and scrutinize each item in order to

ensure that we did not turn off essential systems that we would want available if possible.

(i.e. brakes, speed brakes, TR's). In this situation with time compression, had we run the

electrical fire/smoke checklist to its completion including BATT EMER, we would have had a

significantly degraded our chance of a successful landing, inability to clear the runway to

evacuate, and potentially blown tires/overrun etc.

The TCAS RA portion of this event was not a good situation. Each time that I think about

whether we could have delayed our descent to coordinate with ATC on traffic, I decide that

no we could not. We had no idea that the airplane was not going to be overcome with

smoke, or worse. I believe that an immediate descent and landing was indeed necessary,

and we did so under emergency authority and without ATC direction away from traffic. I

credit the PIC for his quick reaction to the RA in arresting our rapid descent and turning

away from the traffic.

It may be worth noting that I had just returned from recurrent training on the tour

immediately preceding this event. I had reviewed the electrical fire/smoke checklist during

my personal study in recurrent. This may have helped in the decision to recognize that we

needed to stop the checklist prior to "emergency braking", and avoid a more dangerous

situation with an un-needed use of emergency braking.

I do not believe that I would have done anything differently if I had do perform this same

event again. If anything, I would have tried to divide my attention as Pilot monitoring (PM)

between the emergency checklist, and assisting the PF in avoiding traffic using TCAS

before it became a critical issue during our emergency descent. I was contacted by

company managers and a union representative after the fact and I was able to discuss the

event to my satisfaction at the time.

I was assigned flight duty the next day on a different aircraft. I showed a few minutes

early in order to visit the mechanics on our aircraft to see if they had found the source. I

was advised at that time by mechanics that they believed the source was a unprotected

set of wires under the forward left galley carpeting. The wires had burned the plastic non-

stick material under the carpet. I do not know what the final resolution was, as the aircraft

was still in maintenance at the time of my filing this report.

Synopsis

A CE-560XLS flight crew reported smoke and fumes on descent so the crew diverted to a

nearby airport. Maintenance found a burned set of wires under the forward left galley

carpeting and believe that to be the smoke's source. The First Officer commented about

the aircraft emergency checklist complexity.

ACN: 1425790 (45 of 50)

Time / Day

Date : 201702


Place

Locale Reference.ATC Facility : ZZZ.TRACON



Environment



Light : Daylight

Ceiling.Single Value : 20000

Aircraft

Reference : X


Make Model Name : Golden Eagle 421



Flight Plan : IFR

Mission : Personal




Component

Aircraft Component : Engine



Person

Reference : 1
















Events




Detector.Person : Observer





Result.Flight Crew : Inflight Shutdown


Assessments



Narrative: 1

Maintenance work had been performed on the right engine (E2), cylinders #2, 4, 6

pushrod seals. Valve covers were removed and reinstalled on each.

Departed, and after being handed off to TRACON (ATC), pilot observed white smoke

exiting right (E2) nacelle top louvers and oil streaming out of the inboard (left) side of the

nacelle. ATC informed the pilot that someone in a truck at the end of the departing runway

had noticed smoke coming from the right engine and asked if we were okay. Pilot informed

ATC that (paraphrase) "We're okay for now, probably residual oil left over from the

maintenance work and washing."

After leveling at 11,000 MSL, pilot monitored E2 oil psi and oil temperature. No abnormal

indications were noted for the first few minutes after leveling. Oil pressure began to

decrease slowly and oil temperature remained unchanged. The pilot informed ATC that a

return was needed. ATC issued a right or left turn at the pilot's discretion. The pilot turned

left 180 degrees. During the turn ATC asked if fire equipment/trucks were requested."

Okay. Yes, that's probably a good idea just in case." Upon wings level direct to [departure

airport], the pilot observed oil pressure further decreasing and a slight increase in oil

temperature (oil PSI/temperature needles indicated in the gauges green arc).

Before shutting down the abnormal engine, the pilot "tested" the single engine flying

capability by reducing the power to idle on the abnormal engine. Once the pilot confirmed

that the normal working engine (E1) could maintain altitude, the pilot informed passengers

(3) that the right engine would be shut down as a precautionary measure to avoid an

unscheduled shutdown during approach/landing (critical phase of flight), to eliminate the

distraction of monitoring the E2 gauges so as to focus attention on landing safely, and to

preclude a possible vibration and/or fire from the affected engine. At this point the oil

pressure and oil temperature were still operating in the normal ranges.

The pilot completed the memory items for an inflight engine shutdown and then completed

the appropriate emergency checklist. Once the E2 engine was shut down, secured, and

appropriate checklists completed, the pilot informed ATC (now Tower as the hand off was

given prior) that the engine had been shut down just to keep everyone in the loop who

was helping during the situation. Tower requested the pilot enter left downwind to land.

The pilot agreed and replied (winds were gusting up to 20 knots from the southwest).

Tower cleared [us] to land. Pilot replied to clearance. A safe and successful landing was

made and the aircraft was taxied to the ramp under its own power (E1).

The same maintenance staff that had completed the work mentioned above immediately

removed the E2 cowlings and inspected the engine. The problem was identified, corrected,

and a maintenance log entry was made.

Synopsis

C421 pilot reported returning to departure airport after noticing smoke and decreasing oil

pressure associated with the right engine.

ACN: 1425561 (46 of 50)

Time / Day

Date : 201702


Place

Locale Reference.ATC Facility : ZZZ.ARTCC


Environment

Flight Conditions : Mixed

Light : Night

Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger



Component

Aircraft Component : Recirculation Fan


Problem : Failed

Person

Reference : 1








Events






Assessments



Narrative: 1

Extract fan began making noise, eventually caused fumes in the cockpit, then during

failure emitted smoke in the cockpit, tripped breaker and eventually failed. Smoke

dissipated by 10,000. Descent as required in mountainous terrain, late at night, to the

nearest airport. Landed underweight on longest runway. All checklists, performance,

briefings were completed, flight attendants and passengers briefed, company messaged on

ACARs. Fire and Rescue was waiting for us on landing, but not required.

Problem began in flight, a ACARs message was sent to Maintenance. No reply during the

remaining time in flight. They could have assisted in pulling a breaker, eliminating the

dangerous condition. Suggest a faster way to get maintenance in flight.

Synopsis

A319 Captain reported an extract fan failed, caused smoke and fumes in the cockpit. Flight

diverted short of destination.

ACN: 1424990 (47 of 50)

Time / Day

Date : 201702


Place



Environment


Light : Daylight

Aircraft

Reference : X



Make Model Name : Beech 1900



Flight Plan : IFR

Mission : Cargo / Freight


Airspace.Class C : ZZZ

Component



Person

Reference : 1









Events




Result.Flight Crew : Overcame Equipment Problem

Assessments



Narrative: 1

During cruise flight, approximately halfway to ZZZ, I noticed a burning smell and visually

detected a small amount of smoke propagating from between the glare shield and

instrument bezel just above the pilot side attitude indicator. All systems continued to

function normally. The smoke lasted a few minutes and did not affect my physiological

state negatively (besides the unpleasant odor), or my ability to complete the flight safely

to the intended destination, which at the time was also the nearest viable airport. I never

felt my safety was threatened or that continuing the flight to the destination would

threaten other airborne aircraft, airport personnel, passengers, or property. Upon landing

all systems continued to function normally through shutdown and the smoke did not

return. I contacted dispatch and related the incident. Maintenance dispatched a

[Company] mechanic to ZZZ to troubleshoot. The mechanic confirmed the burning odor,

but could not reproduce the problem or pinpoint the cause. After consulting with our Head

of Maintenance and Chief Pilot it was determined to ferry the plane back to [a different

airport], DVFR, to continue with a more thorough inspection.

Callback: 1

The reporter stated that never before has he encountered this kind of incident in this type

of aircraft. The reporter stated that they were flying in lots of moisture and he felt this

may have contributed to the problem. The reporter also stated that Maintenance

completely disassembled the front of the instrument panel and were unable to find

anything that could have contributed to the burning smell. The reporter stated that he has

flown this aircraft several times and has not been able to duplicate the problem. The

reporter stated it seemed like it was just an anomaly that this occurred because he hasn't

seen it since. The reporter stated that because this is an older aircraft it may also be part

of the problem.

Synopsis

Beach 1900 Captain reported a burning smell and smoke coming from behind the glare

shield.

ACN: 1423970 (48 of 50)

Time / Day

Date : 201702


Place




Environment


Light : Daylight

Aircraft

Reference : X


Make Model Name : RV-8



Flight Plan : None

Mission : Personal




Component : 1

Aircraft Component : DC Battery



Component : 2




Person

Reference : 1





Qualification.Flight Crew : Flight Engineer







Events






Assessments



Narrative: 1

While flying a level 360-degree turn (for a compass calibration test), we briefly noticed

(for a few seconds), an acrid odor that quickly stopped. We terminated the test and

headed southwest and climbed from approximately 7500 MSL to 8500 MSL. Examining the

instruments, I noted that the amperage and the battery voltage were fluctuating (within

the green band). [A few minutes later], we began to smell a "solvent type" odor. The

ammeter reading increased to 44 amps, the battery volts increased to 19.8 volts, and the

electrically powered fuel indicator failed. We began an immediate descent, and all

electrical switches were turned off. A few moments later, we began getting smoke in the

cockpit from behind the instrument panel, and we began a high-speed emergency descent.

This was followed by a dramatic increase in smoke density, making it difficult to breathe,

and reducing visibility in the front cockpit to near zero. We opened the canopy in order to

evacuate the smoke, and landed on the nearest available road. After landing, the smoke

continued from behind the instrument panel, [and] I applied Halon to the area. After

exiting the aircraft, we determined the smoke was coming from the battery compartment.

We applied the remainder of the Halon, and then poured dirt into the battery compartment

to extinguish the fire.

The time from the initial odor/high electrical reading, until landing, was approximately 4 to

7 minutes.

Battery Type: EarthX ETX 680 (approx 2.7 hrs of use).

Alternator/Voltage Regulator: Bosch

EFIS/Engine Instrumentation: Dynon Skyview HDX

Synopsis

RV-8 pilot reported landing on a small road after the cockpit filled with smoke from an

electrical system problem.

ACN: 1423884 (49 of 50)

Time / Day

Date : 201702


Place



Environment

Light : Daylight

Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger

Flight Phase : Final Approach


Person : 1

Reference : 1








Person : 2

Reference : 2








Person : 3

Reference : 3









Events






Assessments



Narrative: 1

There was a strong odor detected during our final approach by myself the B-FA. I felt

symptoms such as coughing, light headed and an itchy throat. We contacted medical as

soon as we landed explained the event to them in full detail. Medical paremedics came

onboard to assist us, checked our vital signs, and removed us from the aircraft with

wheelchairs. A police officer who came onboard to help the paramedics became ill as well.

The A-FA notified the flight deck what happened instantly upon landing. The C-FA also felt

symptoms of headaches, sore throat, and light headed.

I suggest the aircraft maintenance crews should perform various fume test (hydraulic

fluid, hazardous chemical) while these aircrafts are in the hangars and on the ramp before

allowing passengers or crewmembers to board them.

Narrative: 2

After strapping in for landing B F/A told me he smelled dirty socks and that he wasn't

feeling well. I told him to cover his nose and mouth with his hand and I did the same. I

smelled the dirty sock smell a minute later then B F/A. When we landed B called the

Captain and reported the event. They called the paramedics who met the flight along with

law enforcement. We all gathered in the first class area to gather information about fume

event. Shortly after a police officer started feeling sick.

We all disembarked aircraft at that time. We were placed in wheel chairs and our vitals

were taken. The pilots headed to their next flight. We did not get a chance to discuss this

further with them, at least I didn't, not sure about the A F/A. The new Captain was filled in

with the details. We were taken to the gate area in wheel chairs and continued to fill out

paperwork. The paramedics checked our vital signs again and we signed paperwork.

The Captain informed scheduling that the F/As were not able to continue working. We

were briefed on procedures about transportation to [the] hospital. The doctor wants the

whole crew to follow up with workman comp clinic. I am feeling very fatigued with intense

headache and dizziness. My throat is very sore. I was involved with a fume event [a few

years ago] as well. I will follow up with company doctor as well as my own.

Narrative: 3

I told the paramedic that I was starting to have difficulty taking deep breaths and felt

short of breath. It felt hard to swallow at times despite me sipping water. I also began to

feel shaky and my skin began to feel really hot. The police officer mentioned how she felt

dizzy so the paramedic had us all get off the aircraft and go into the terminal to be

checked by paramedics.

Synopsis

A319 flight attendants reported being transported to the hospital after inhaling toxic fumes

in the cabin while on final approach.

ACN: 1423880 (50 of 50)

Time / Day

Date : 201702

Place




Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger

Flight Phase : Initial Approach


Person

Reference : 1


Location In Aircraft : Galley





Events






Assessments



Narrative: 1

[Acrid] fumes filled the 1LR and 2LR galley at altitude of 7,000 feet. Same as former fume

events. Acrid sweet dirty smell with irritation to throat. After landing, told the pilots. Was

told it was deicing fluid. No, it wasn't. The plane had sat at the departure airport since the

day before and we didn't deice. It was NOTHING like deciding fluid. I have been in 5 fume

events. I am very familiar with the smell. We have this plane again tomorrow. Plane needs

to be removed from service and identify the source of the leaking oil getting into air bleed

system.

Synopsis

A330 Flight Attendant reported throat irritation after noticing an acrid fume smell in the

galley in flight.

cabin smoke, fire, fumes, or odor incidents - aviation safety

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