37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 404490 |
Time | |
Date | 199806 |
Day | Tue |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : lny airport : ogg |
State Reference | HI |
Altitude | msl bound lower : 9000 msl bound upper : 9000 |
Environment | |
Flight Conditions | Mixed |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zhn |
Operator | common carrier : air carrier |
Make Model Name | Shorts SD-330-200/Utt/Sherpa |
Operating Under FAR Part | Part 121 |
Flight Phase | cruise other other |
Route In Use | enroute : on vectors enroute airway : zhn |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 105 flight time total : 10000 flight time type : 1650 |
ASRS Report | 404490 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : cfi pilot : commercial pilot : instrument |
Experience | flight time last 90 days : 75 flight time total : 950 flight time type : 250 |
ASRS Report | 404489 |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : far other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : declared emergency other |
Consequence | other Other |
Supplementary | |
Primary Problem | Aircraft |
Narrative:
We had just leveled off at 9000 ft when we detected what we thought were toxic fumes in the cockpit. I told the first officer to get the oxygen masks out and turn the oxygen on. The masks were the plastic type that you have to pull aside to use the microphone to communicate. I also asked her to turn the air conditioning on, which seemed to get rid of the smell somewhat. The first officer stated that she was feeling kind of funny or light headed. I was also feeling strange and not reacting normally. I asked her to ask center for a deviation to kahului, maui. For some reason initially we were given a vector directly away from the kahului airport. This confused me, however, I did manage to clarify it and was given a vector to kahului and descent clearance. We descended through a cloud layer and then made a visual approach and landed at the kahului airport. The workload in the cockpit seemed extremely taxing. To communicate with ATC and my first officer I was constantly putting the oxygen mask aside so I could talk into the microphone. As I did this I was probably getting little or no oxygen and I believe we ran out of oxygen before we reached airport. After landing we were taken to the hospital where we were put on 100% oxygen under positive pressure. After about 1 hour of breathing the oxygen, we began to 'come to' and realize how serious a situation we were in. I don't think we were actually incapacitated, however, it was clear to us that we were not performing very well at what should have been routine tasks on the descent and approach. The hazmat team found a fuel pump with gasoline in it in the nose compartment. Apparently it had purged at altitude with the fumes coming to the cockpit. It was not marked or labeled as dangerous goods. I believe we became hypoxic because of the toxic fumes we were breathing. Looking back on the event I know I was not performing very well. I didn't realize it at the time and really didn't care. I don't know what can be done to get shippers to properly package and label dangerous goods. Even if this package was labeled as a flammable liquid, it still was not packed in a way to keep the fumes from coming out of it. One thing that I think should be mandatory on cargo aircraft is a quick-don oxygen mask providing oxygen under positive pressure with an oxygen supply sufficient to get you to a suitable airport. This mask should contain a microphone so you are able to communication without breathing contaminated air. Had we had such a mask available, I believe our deviation approach and landing would have been almost routine. Callback conversation with reporter revealed the following information: the captain stated that the oxygen masks were like a 'hospital type' with a breather bag or similar to the 'drop' masks in a pressurized airliner cabin. Real 'mickey mouse.' he added that the other cargo aircraft (C208's) had good masks that were pressurized and that the company was going to obtain similar type masks for the sd-330's. The oxygen bottles were only 2/3 - 3/4 full, which is a normal amount for this operation. He said he could not find any listed endurance times for the oxygen in the pilot's operating handbook but thought that everyone expected at least 15 mins of operation at full flow. The carrier is part 121 and 135, with his cargo flight a part 135 operation. The shipper had placed an automatic fuel pump in a box. The residual fuel from the pump had leaked out through the packaging material, which then vaporized. The SD330 is not pressurized. The captain had the first officer turn on the air conditioning to assist in dissipating the fumes. Captain also stated that the box was shipped from jax, fl, and according to the PIC, the FAA is after this shipper who should have known better. Supplemental information from acn 404489: I supervised the loading of the cargo as usual in hnl and did not notice anything unusual. All of the declared hazmat was loaded in the correct zones and had the appropriate paperwork. On taxi, we were called back for more freight. Takeoff was then normal. As I began my level-out I noticed a synthetic smell. We did not declare an emergency. Although we did not declare an emergency, the crash fire rescue equipment crews met us. We got out of the plane quickly and the crews began looking for the source of the smell. The captain called our dispatch, who in turn contacted our poi (FAA). We contacted the hazmat specialists and then left for the hospital where we underwent ekg's, chest x-rays, and blood gas tests. My blood pressure was elevated and I was feeling very disconnected and spacey. We were in denial about the seriousness of the situation and although we completed our duties normally, it seemed very taxing to do our duties normally. We should have declared an emergency. We found our oxygen system to be inadequate. We were out of oxygen within 10 mins and had to remove the masks to communicate. The company insisted I file a company 'incident' report to be faxed to dispatch and the chief pilot that night. I was scheduled to fly the next day and was hit with a form I was asked to sign releasing all medical information to all parties involved. Callback conversation with reporter revealed the following information: the first officer stated that the type number of the mask was not known. It was simply a breather bag type, unpressurized. The oxygen bottles were 3/4 full because maintenance does not fill them all the way since the bottles seem to be affected by the temperatures experienced on the ramp. No endurance was listed in the pom for the oxygen bottles. The unmarked hazmat box was placed on board the aircraft during the initial loading procedure but was not recognized as hazmat since it wasn't marked as such. The first officer said that it costs the shipper more if it is marked hazmat. 3 days later, this same shipper tried to ship the same pump that was offloaded in ogg without listing it as hazmat. The company personnel recognized the box and did not load it on the aircraft. The company is checking out this problem regarding the masks. Safety suggestion: why can't companies adjust prices so that hazmat shipments cost less than regular packages, sort of a 'reward' for listing the hazmat.
Original NASA ASRS Text
Title: AN SD330 FLC DIVERTS TO OGG FROM NEAR LNY, HI, WHEN THE CREW STARTS TO FEEL 'SPACEY' AFTER DETECTING UNKNOWN FUMES IN THE COCKPIT. THE AROMA CAME FROM HAZMAT, GASOLINE IN A FUEL PUMP.
Narrative: WE HAD JUST LEVELED OFF AT 9000 FT WHEN WE DETECTED WHAT WE THOUGHT WERE TOXIC FUMES IN THE COCKPIT. I TOLD THE FO TO GET THE OXYGEN MASKS OUT AND TURN THE OXYGEN ON. THE MASKS WERE THE PLASTIC TYPE THAT YOU HAVE TO PULL ASIDE TO USE THE MIKE TO COMMUNICATE. I ALSO ASKED HER TO TURN THE AIR CONDITIONING ON, WHICH SEEMED TO GET RID OF THE SMELL SOMEWHAT. THE FO STATED THAT SHE WAS FEELING KIND OF FUNNY OR LIGHT HEADED. I WAS ALSO FEELING STRANGE AND NOT REACTING NORMALLY. I ASKED HER TO ASK CTR FOR A DEV TO KAHULUI, MAUI. FOR SOME REASON INITIALLY WE WERE GIVEN A VECTOR DIRECTLY AWAY FROM THE KAHULUI ARPT. THIS CONFUSED ME, HOWEVER, I DID MANAGE TO CLARIFY IT AND WAS GIVEN A VECTOR TO KAHULUI AND DSCNT CLRNC. WE DSNDED THROUGH A CLOUD LAYER AND THEN MADE A VISUAL APCH AND LANDED AT THE KAHULUI ARPT. THE WORKLOAD IN THE COCKPIT SEEMED EXTREMELY TAXING. TO COMMUNICATE WITH ATC AND MY FO I WAS CONSTANTLY PUTTING THE OXYGEN MASK ASIDE SO I COULD TALK INTO THE MIKE. AS I DID THIS I WAS PROBABLY GETTING LITTLE OR NO OXYGEN AND I BELIEVE WE RAN OUT OF OXYGEN BEFORE WE REACHED ARPT. AFTER LNDG WE WERE TAKEN TO THE HOSPITAL WHERE WE WERE PUT ON 100% OXYGEN UNDER POSITIVE PRESSURE. AFTER ABOUT 1 HR OF BREATHING THE OXYGEN, WE BEGAN TO 'COME TO' AND REALIZE HOW SERIOUS A SIT WE WERE IN. I DON'T THINK WE WERE ACTUALLY INCAPACITATED, HOWEVER, IT WAS CLR TO US THAT WE WERE NOT PERFORMING VERY WELL AT WHAT SHOULD HAVE BEEN ROUTINE TASKS ON THE DSCNT AND APCH. THE HAZMAT TEAM FOUND A FUEL PUMP WITH GASOLINE IN IT IN THE NOSE COMPARTMENT. APPARENTLY IT HAD PURGED AT ALT WITH THE FUMES COMING TO THE COCKPIT. IT WAS NOT MARKED OR LABELED AS DANGEROUS GOODS. I BELIEVE WE BECAME HYPOXIC BECAUSE OF THE TOXIC FUMES WE WERE BREATHING. LOOKING BACK ON THE EVENT I KNOW I WAS NOT PERFORMING VERY WELL. I DIDN'T REALIZE IT AT THE TIME AND REALLY DIDN'T CARE. I DON'T KNOW WHAT CAN BE DONE TO GET SHIPPERS TO PROPERLY PACKAGE AND LABEL DANGEROUS GOODS. EVEN IF THIS PACKAGE WAS LABELED AS A FLAMMABLE LIQUID, IT STILL WAS NOT PACKED IN A WAY TO KEEP THE FUMES FROM COMING OUT OF IT. ONE THING THAT I THINK SHOULD BE MANDATORY ON CARGO ACFT IS A QUICK-DON OXYGEN MASK PROVIDING OXYGEN UNDER POSITIVE PRESSURE WITH AN OXYGEN SUPPLY SUFFICIENT TO GET YOU TO A SUITABLE ARPT. THIS MASK SHOULD CONTAIN A MIKE SO YOU ARE ABLE TO COM WITHOUT BREATHING CONTAMINATED AIR. HAD WE HAD SUCH A MASK AVAILABLE, I BELIEVE OUR DEV APCH AND LNDG WOULD HAVE BEEN ALMOST ROUTINE. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE CAPT STATED THAT THE OXYGEN MASKS WERE LIKE A 'HOSPITAL TYPE' WITH A BREATHER BAG OR SIMILAR TO THE 'DROP' MASKS IN A PRESSURIZED AIRLINER CABIN. REAL 'MICKEY MOUSE.' HE ADDED THAT THE OTHER CARGO ACFT (C208'S) HAD GOOD MASKS THAT WERE PRESSURIZED AND THAT THE COMPANY WAS GOING TO OBTAIN SIMILAR TYPE MASKS FOR THE SD-330'S. THE OXYGEN BOTTLES WERE ONLY 2/3 - 3/4 FULL, WHICH IS A NORMAL AMOUNT FOR THIS OP. HE SAID HE COULD NOT FIND ANY LISTED ENDURANCE TIMES FOR THE OXYGEN IN THE PLT'S OPERATING HANDBOOK BUT THOUGHT THAT EVERYONE EXPECTED AT LEAST 15 MINS OF OP AT FULL FLOW. THE CARRIER IS PART 121 AND 135, WITH HIS CARGO FLT A PART 135 OP. THE SHIPPER HAD PLACED AN AUTO FUEL PUMP IN A BOX. THE RESIDUAL FUEL FROM THE PUMP HAD LEAKED OUT THROUGH THE PACKAGING MATERIAL, WHICH THEN VAPORIZED. THE SD330 IS NOT PRESSURIZED. THE CAPT HAD THE FO TURN ON THE AIR CONDITIONING TO ASSIST IN DISSIPATING THE FUMES. CAPT ALSO STATED THAT THE BOX WAS SHIPPED FROM JAX, FL, AND ACCORDING TO THE PIC, THE FAA IS AFTER THIS SHIPPER WHO SHOULD HAVE KNOWN BETTER. SUPPLEMENTAL INFO FROM ACN 404489: I SUPERVISED THE LOADING OF THE CARGO AS USUAL IN HNL AND DID NOT NOTICE ANYTHING UNUSUAL. ALL OF THE DECLARED HAZMAT WAS LOADED IN THE CORRECT ZONES AND HAD THE APPROPRIATE PAPERWORK. ON TAXI, WE WERE CALLED BACK FOR MORE FREIGHT. TKOF WAS THEN NORMAL. AS I BEGAN MY LEVEL-OUT I NOTICED A SYNTHETIC SMELL. WE DID NOT DECLARE AN EMER. ALTHOUGH WE DID NOT DECLARE AN EMER, THE CFR CREWS MET US. WE GOT OUT OF THE PLANE QUICKLY AND THE CREWS BEGAN LOOKING FOR THE SOURCE OF THE SMELL. THE CAPT CALLED OUR DISPATCH, WHO IN TURN CONTACTED OUR POI (FAA). WE CONTACTED THE HAZMAT SPECIALISTS AND THEN LEFT FOR THE HOSPITAL WHERE WE UNDERWENT EKG'S, CHEST X-RAYS, AND BLOOD GAS TESTS. MY BLOOD PRESSURE WAS ELEVATED AND I WAS FEELING VERY DISCONNECTED AND SPACEY. WE WERE IN DENIAL ABOUT THE SERIOUSNESS OF THE SIT AND ALTHOUGH WE COMPLETED OUR DUTIES NORMALLY, IT SEEMED VERY TAXING TO DO OUR DUTIES NORMALLY. WE SHOULD HAVE DECLARED AN EMER. WE FOUND OUR OXYGEN SYS TO BE INADEQUATE. WE WERE OUT OF OXYGEN WITHIN 10 MINS AND HAD TO REMOVE THE MASKS TO COMMUNICATE. THE COMPANY INSISTED I FILE A COMPANY 'INCIDENT' RPT TO BE FAXED TO DISPATCH AND THE CHIEF PLT THAT NIGHT. I WAS SCHEDULED TO FLY THE NEXT DAY AND WAS HIT WITH A FORM I WAS ASKED TO SIGN RELEASING ALL MEDICAL INFO TO ALL PARTIES INVOLVED. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE FO STATED THAT THE TYPE NUMBER OF THE MASK WAS NOT KNOWN. IT WAS SIMPLY A BREATHER BAG TYPE, UNPRESSURIZED. THE OXYGEN BOTTLES WERE 3/4 FULL BECAUSE MAINT DOES NOT FILL THEM ALL THE WAY SINCE THE BOTTLES SEEM TO BE AFFECTED BY THE TEMPS EXPERIENCED ON THE RAMP. NO ENDURANCE WAS LISTED IN THE POM FOR THE OXYGEN BOTTLES. THE UNMARKED HAZMAT BOX WAS PLACED ON BOARD THE ACFT DURING THE INITIAL LOADING PROC BUT WAS NOT RECOGNIZED AS HAZMAT SINCE IT WASN'T MARKED AS SUCH. THE FO SAID THAT IT COSTS THE SHIPPER MORE IF IT IS MARKED HAZMAT. 3 DAYS LATER, THIS SAME SHIPPER TRIED TO SHIP THE SAME PUMP THAT WAS OFFLOADED IN OGG WITHOUT LISTING IT AS HAZMAT. THE COMPANY PERSONNEL RECOGNIZED THE BOX AND DID NOT LOAD IT ON THE ACFT. THE COMPANY IS CHKING OUT THIS PROB REGARDING THE MASKS. SAFETY SUGGESTION: WHY CAN'T COMPANIES ADJUST PRICES SO THAT HAZMAT SHIPMENTS COST LESS THAN REGULAR PACKAGES, SORT OF A 'REWARD' FOR LISTING THE HAZMAT.
Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.