
Spirit A319 at Boston, Jul 17th 2015, fumes on board, captain died 50 days later - hugh-avherald
https://avherald.com/h?article=4b6eb830&opt=0
======
bhickey
The captain flew the next day without seeking medical treatment after being
incapacitated midflight? That's outrageous if I'm reading this right.

~~~
cmurf
This is a blatant violation of 49 CFR 830.5(a)(2). It's an explicitly listed
incident that requires immediate reporting by the pilot. I can't find a
definition for immediate, but as a pilot I consider it to mean today, not
tomorrow. If it were a clearance, immediate means right now, not even one
minute from now and if I can't do it right now, I would right now reply
"unable: reason(s)"

And a big part of why I expect this is because ATC collects a shittonne (an SI
unit) of data per day, and I don't expect they have a very long retention for
that data. The accident and incident reporting requirements are meant to make
sure that data is preserved. I have zero expectation of data retention for
flight plans, audio tapes, radar tape, beyond 30 days. I would not be suprised
if it were 7 days.

Neither pilot reported this incident? And the surviving pilot admits he did
not file a required incident report but he's done a recorded public
presentation on an incident that has a mandatory incident reporting
requirement? And his excuse is intimidation by his employer, which is probably
a crime? What?

I don't have time to dig through all of this, so maybe I've missed something,
but something does not pass the smell test.

~~~
oh_sigh
Perhaps the problem is self reporting? If the captain is still mentally
affected, he might not remember to follow through with that? Or he might not
have understood that he was even incapacitated at that point.

------
lainga
For the confused, the captain's symptoms were "consistent with ToCP
poisoning", meaning

[https://en.wikipedia.org/wiki/Tricresyl_phosphate](https://en.wikipedia.org/wiki/Tricresyl_phosphate),

which is used as "an additive in turbine engine oil".

~~~
tlb
That is some nasty stuff. Can someone who understands lubricants explain the
need for it in lubricating oil? Is it to keep mold from growing in the oil, or
does it have essential anti-wear properties?

~~~
gruez
from the wikipedia page:

>It is used as an antiwear and extreme pressure additive in lubricants and
hydraulic fluids.[2][3]

~~~
tlb
This explains the chemical mechanism:
[https://en.wikipedia.org/wiki/Extreme_pressure_additive](https://en.wikipedia.org/wiki/Extreme_pressure_additive)

An important property is that when localized hot-spots appear on metal
surfaces due to friction, the heat causes a chemical reaction that bonds the
molecule to the metal preventing further wear. Organophosphates like ToCP do
this at higher temperatures than some less toxic compounds, presumably
important in jet engines. So they're not just mixing in random poisons for no
reason.

------
neurotech1
The AvHerald & Simon Hradecky is well respected in the aviation community for
factually reporting incidents and accidents in a balanced and non-dramatized
manner.

He has posted numerous times regarding fume events, which occur somewhat
frequently on the A320 series airliners, and less frequently on other types.

------
owenversteeg
Nobody commenting about bleed air sensors? I think that bleed air sensors are
the obvious solution here, expensive and difficult to add but with the claimed
almost 2000 fume incidents per day it seems like they are fairly low-hanging
fruit.

Anyone with more experience know about this? e.x. how expensive they would be
to add?

There's this screenshot from a presentation about bleed air sensors (from the
article)
[http://avherald.com/img/spirit_a319_n519nk_boston_150717_3.j...](http://avherald.com/img/spirit_a319_n519nk_boston_150717_3.jpg)
I suppose in this case the "sensors" worked but there was interference from
higher-ups:

"While the flight crew was considering what to do next, the assistant chief
pilot of the airline boarded the aircraft and told the crew off, that they
didn't know what they were doing and they were wrong in pushing for further
maintenance action."

------
dmitrygr
A fun little tidbit for you all.

As far as FAA is concerned, this death will _not_ count as related to that
fume situation. For something to be an "accident", it must meet a few
criteria, one of them is causing a death or serious injury. A fatal injury
related to an accident is defined in 8020.11C as

    
    
       > Fatal Injury - any injury which results 
       > in death within 30-days of the accident. 
    

It will not even count as a "serious injury"

    
    
       >  Serious Injury - any injury which:  (1)
       > requires hospitalization for more than 48
       > hours,  commencing within 7-days from the
       > date an injury was received; (2) results
       > in a fracture of any bone (except simple
       > fractures of fingers, toes, or nose); (3)
       > causes severe hemorrhages, or nerve,
       > muscle, or tendon damage; (4) involves
       > any internal organ; or (5) involves
       > second- or third-degree burns, or any
       > burns affecting more than 5-percent of
       > the body surface. 
    

Further reading:
[https://www.faa.gov/documentLibrary/media/Order/8020.11C_.pd...](https://www.faa.gov/documentLibrary/media/Order/8020.11C_.pdf)

~~~
jakobegger
Wouldn't "(4) involves any internal organ" apply? As I understood it the
pilots internal organs (lung, brain, etc) were severely injured by the toxic
fumes.

------
doodlebugging
This really opens my eyes. My wife flies frequently, usually on AA but
sometimes on others. For years, really for as long as I remember she would
spend the first day or so fighting stomach problems, headache, etc. and after
the return flight she would inevitably have similar symptoms that she always
attributed to food eaten while on the road.

I finally just warned her to avoid the shrimp or seafood since we rarely eat
it when at home but it seemed like every time she traveled she ended up at a
restaurant and had some kind of sea food.

It didn't help because just last week she returned home, again with headache,
nausea, sinus problems, etc. that kept her sidelined for part of the weekend.

I am going to look into test strips to detect these substances that she could
carry on the plane with her to see whether any correlates.

Her assignments see her needing to fly as it is too far to drive in a
realistic time frame to most of the meetings but maybe a career change might
solve this if it is the cause of her post-flight issues.

Anyone else have similar observations or observations that would indicate this
is likely not an issue? I'm open for any discussions.

~~~
jowiar
Those symptoms strike me as altitude sickness-esque -- they're what a friend
of mine experienced when we went to Bogota. A quick google seems to indicate
that altitude sickness from flying is a thing for some people.

[https://well.blogs.nytimes.com/2012/05/28/really-flying-
can-...](https://well.blogs.nytimes.com/2012/05/28/really-flying-can-cause-
mountain-sickness/)

~~~
ghaff
It wouldn't shock me. Cabin pressurization depends on the plane--maybe the
airline(?)--but my understanding is that it's to about 6K to 8K feet. In other
words, higher than Denver but lower than Quito or many US West ski areas.
Serious altitude sickness does happen in Colorado. I've heard of it happening
in Denver itself but it's at least rare. I'm not sure it's a likely
explanation but it's at least possible.

~~~
tpkj
From the World Health Organization:

> "Although aircraft cabins are pressurized, cabin air pressure at cruising
> altitude is lower than air pressure at sea level. At typical cruising
> altitudes in the range 11 000–12 200 m (36 000–40 000 feet), air pressure in
> the cabin is equivalent to the outside air pressure at 1800–2400 m
> (6000–8000 feet) above sea level. As a consequence, less oxygen is taken up
> by the blood (hypoxia) and gases within the body expand. The effects of
> reduced cabin air pressure are usually well tolerated by healthy
> passengers."

[http://www.who.int/ith/mode_of_travel/cab/en/](http://www.who.int/ith/mode_of_travel/cab/en/)

While the NY Times blog link earlier in this chain of comments had a
recommendation about reducing cabin air pressure to 6,000 ft, I question how
useful that is, since for those susceptible to altitude sickness, 6,000 feet
is going to be enough to trigger symptoms for many.

These next two articles are not devoted to airline travel per se, but about
high altitude related sickness.

From "Preparing for Safe Travel to High Altitude", by Paul Anderson, M.D.

> "High Altitude Illnesses (HAI) include Acute Mountain Sickness (AMS), High-
> Altitude Pulmonary Edema (HAPE), and High-Altitude Cerebral Edema (HACE).
> The symptoms of AMS are typically felt by most people when they arrive at a
> new altitude, but the symptoms are usually self limiting (e.g. 1st 3-5 days
> at high altitude). The exact mechanisms of AMS remain unclear, however
> symptoms tend to be the most prevalent 1-2 days after arrival at elevation.
> The most common symptoms include a headache, gastrointestinal upset,
> feelings of fatigue, dizziness, and sleep disruption. ..."

[http://www.mayo.edu/research/documents/preparing-for-safe-
tr...](http://www.mayo.edu/research/documents/preparing-for-safe-
travelpdf/doc-10026905)

From "Altitude-Related Illnesses", Mayo Clinic Preceedings:

> "... An estimated 30 million people are at risk for altitude related
> illnesses in the western United States annually. Many cases are unrecognized
> by the victims and by their physicians who may attribute symptoms to viral
> illness, “hangover,” or fatigue. In addition, commercial airline travel
> exposes passengers to a cabin pressure equivalent of 2,500 m and allows them
> to travel rapidly to high altitude destinations such as Aspen or Steamboat
> Springs, Colorado, where they may be exposed to even greater altitudes.

... The rate of ascent and a prior history of altitude illness are the major
determinants of a person's susceptibility to altitude illness. Aerobic fitness
does not correlate with the likelihood of acquiring AMS."

(See especially the symptoms of Acute Mountain Sickness in this article.)

[http://www.mayoclinicproceedings.org/article/S0025-6196(11)6...](http://www.mayoclinicproceedings.org/article/S0025-6196\(11\)63396-X/fulltext)

------
Reason077
Hopefully, future aircraft designs will follow the Boeing 787 in eliminating
the bleed air system, which is the likely culprit in these kind of cabin air
contamination events.

~~~
apaprocki
In the past few years I've flown a bunch on the AA A321T configuration, brand
new planes. I was shocked at just how much better the 787 is in almost all
regards in terms of the environmental quality of being on the plane. From the
air, to the noise.. everything was noticeably better. When the A321T lands,
the noise created was peaking ridiculous dB and hurting my ears. I was
expecting something similar on the 787 and chalked it up to "lighter/thinner
materials, more sound gets through" and it was shockingly almost silent by
comparison.

~~~
thesumofall
Sorry, but those are just two entirely different planes with very different
requirement sets. One is a wide body the other is a narrow body, for starters.
A350 vs 787 is a slightly better, if still not perfect, comparison

~~~
avs733
A better way to look at it is that they are two different generations of
planes. I fly/have flown a lot in a prior role.

Excepting the 747, which let you get so far away from the engines that it was
often irrelevant, newer planes create significantly improved passenger
experiences (ignoring seat pitch).

The A350 (2013 First Flight) , A380 (2005FF), and B787 (2009FF) are
significant cabin environmental quality improvements over the A330(1992FF),
A340(1991FF), B777(1994FF). They aren't just using different materials that
are using IMMENSELY different technology and computing power in the design
process. That lets the engineers pay attention to details they couldn't
before.

For Comparison (look at the front and rear wings especially:

1994(B777era) F1-straight lines, single curves, few compound surfaces [0]

2005(B787era) F1-lots of curves, compound curse galore, intentionally designed
interactions of surfaces [1]

Thats the different in design capacity driven by computing tools and
technology.

[0] [http://www.spannerhead.com/wp-
content/uploads/2012/02/Ferrar...](http://www.spannerhead.com/wp-
content/uploads/2012/02/Ferrari_412_T2.jpg)

[1]
[https://en.wikipedia.org/wiki/2009_FIA_Formula_One_World_Cha...](https://en.wikipedia.org/wiki/2009_FIA_Formula_One_World_Championship#/media/File:Heikki_Kovalainen_Jerez_Feb_2009_3611a.jpg)

~~~
tavert
2008 or 2017-2018 would be more dramatic examples of recent Formula 1 aero
taken to extremes - 2009 was the most aerodynamically restricted year in
recent regulations.

~~~
avs733
I know but I was going for what lined up to make my point :)

If you look at details, the progression from 94 to 2008 is HUGE but its very
much in details. That was the point more so than figuring out which McLaren
had the most appendages.

------
tpkj
1\. Has anyone done investigative work on the passengers of this flight and
their subsequent health status? How many visited a doctor with symptoms
similar to the crew? Were there any fatalities among the passengers in the
weeks following the flight?

2\. How many years away would you estimate the the commercial aviation
industry is from avoiding this type of toxic air problem? Are newer aircraft
still susceptible to air quality issues like this? Does a radically new
approach such as solar powered flight reduce these issues?

------
ajnin
For those like me who are not familiar with aviation topics, "bleed air" is
air taken from the compressor stage of the engines and used to pressurize the
cabin. Not all aircraft use this system and some have an option to use this or
some other system to pressurize cabin air.

~~~
tavert
The 787 is the only jet-powered passenger aircraft I'm aware of that doesn't
use a bleed air system. Any pressurized-cabin turboprop aircraft uses bleed
air, and so does the M1 Abrams tank. Bleed air is not just used for cabin
pressurization, it's also used for anti-icing systems, cabin temperature
control (the high-pressure air is the working fluid, see
[https://en.wikipedia.org/wiki/Air_cycle_machine](https://en.wikipedia.org/wiki/Air_cycle_machine)),
and nitrogen generation systems for fuel tank inerting.

(I worked on the environmental control system for the Gulfstream G650 many
years ago)

~~~
da02
When you fly commercial, is the 787 your favorite? Or do you recommend other
aircraft?

------
13of40
I'd just like to chime in that I'm on a plane right now and the slight foot
odor permeating the cabin is driving me nuts after reading that article.

~~~
CodeWriter23
Just remember, you are at statistically much higher risk of death or being
maimed while crossing the street, something you likely do every day.

~~~
oh_sigh
That's for general aviation travel. What are the chances of death when in an
airplane that has a strange smell?

------
StringyBob
So, could this kind of thing have caused the MH370 disappearance?

It's a stretch, but perhaps similar cockpit confusion caused by oxygen
deprivation or ToCP poisoning (from a gas leak) could have been a reason to
change direction (before passing out)?

~~~
avs733
Theoretically I could see how, but my impression was that there wasn't a
single flight path change but multiple changes and possibly even active effort
to avoid radar [1]. That seems more cognitively engaged than the routinous
behavior described in the article.

[1][https://www.telegraph.co.uk/news/worldnews/asia/malaysia/108...](https://www.telegraph.co.uk/news/worldnews/asia/malaysia/10802361/MH370-Malaysia-
report-indicates-plane-flew-route-to-avoid-detection.html)

------
Jesus_Jones
This looks like a serious issue that the faa should investigate. Since they
look at so many problems and frequently issue repair orders, recalls, etc by
certain dates, why would they treat this particular issue so differently?

------
sailfast
Any mitigation to this as passengers? Given the security environment these
days I'd hate to be they guy that starts yelling "I smell dirty socks - drop
the oxygen masks!" when it was actually dirty socks. Given the odds / number
of events does a rational person bring a basic respirator for themselves and
their family?

~~~
encoderer
Reading the letter, reading between the lines, it seems like an airline would
have to report this to NTSB/FAA if a passenger requests medical assistance
upon landing. We're always in a hurry when flying which probably contributes
to under-reporting.

It also feels like the primary risk here is that the pilots will pass out and
crash the plane, not main cabin toxicity. The pilot in his letter states
clearly that had he not put on his mask when he felt the onset of tunnel
vision "we would've killed every person on that aircraft". By that point the
captain was already slumped over, eyes half open in a dead stare. Meanwhile
200+ people are in the back oblivious.

Chilling.

~~~
lazerpants
But wouldn't the air bleed of ToPC effect the passengers? And if so, wouldn't
that mean Spirit could be on the hook for passengers who suffered as a result?

~~~
encoderer
Yes but I’m guessing air volume of cabin vs cockpit could explain why nobody
passed out in mc?

~~~
lazerpants
I don't know anything about aerospace HVAC, but wouldn't the larger cabin
volume necessitate a larger exchange of usable air, and therefore bring in
just as much ToPC as in the cockpit? I.e., isn't the volume adjusted for
regardless?

------
iooi
Is anyone else not surprised to see this from Spirit? They are absolutely the
worst carrier I've flown with in the states. Nothing is on time, everything
seems dirty, and nobody that works there seems to care about anything.

~~~
crabl
You've clearly never flown with Allegiant...

~~~
sjm-lbm
I don't know if you are joking or not, but the point you are making is very
legitimate. Over the past few years, there has been reason to be unusually
concerned with Allegiant’s maintenance practices.

(see here: [https://www.travelpulse.com/news/impacting-travel/is-
allegia...](https://www.travelpulse.com/news/impacting-travel/is-allegiant-
americas-most-dangerous-airline.html))

~~~
crabl
Definitely not a joke, unfortunately. I've personally had way too many
concerns to justify ever traveling with them again.

------
a2tech
This article is poorly worded and does a poor job of forwarding their
argument. The overall tone of the article is amateurish and feels more like an
article you might find arguing against vaccinations.

The claims presented in the article are extremely serious-if what they're
claiming is true, the FAA, major airlines, and pilots unions have all been
sitting on 'fume events', or actively suppressing knowledge of them.

~~~
blueflow
The Aviation Herald is recognized as accepted industry service for safety
relevant occurrences. This is the closest you get to first-hand, factual and
objective journalism. It does not intend to bring any argument forward (like
opinion-making "journalism"), but instead inform people, primary aviators
themselves. Thats also the reason for the technical wording.

Your comment is the epitome of ignorance on HN.

~~~
Jesus_Jones
I also thought the article's trustworthiness based on how it was written and
presented was difficult to ascertain. I had never heard of that publication.

