Aer Lingus Airbus A320-214 El-DVJ, 2015

NASR, AHMAD / MELO, SAGRIED DONIZ / TANDICO, AL RYAN

/ ALVARO, ALLEN / BS-AET/3B/AMTA 329

SIR BRIAN NOLASCO

 INTRODUCTION

On 3 October 2015, an Airbus A320 (EI-DVJ) operating a scheduled international passenger

flight from Dublin to Munich It was noted that the 40 year-old male aircraft commander, who
had been PF for the flight, had 10,523 total flying hours which included 6,691 hours on type. The
27 year-old female First Officer had 2,067 total flying hours which included 1,771 hours on type.
Both pilots held licences issued by the Irish Aviation Authority. The aircraft had just taken off
when noxious fumes became apparent throughout the aircraft and a 'smoke-like effect' was
observed in the cabin. The effects fluctuated but continued and a PAN for an air turnback was
declared to ATC with the pilots donning oxygen masks as a precaution. The aircraft landed back
at Dublin just over 20 minutes later and after an unexpected delay due to absence of ground staff,
the doors were opened and all occupants were disembarked. The episode had no identifiable
injurious effects on the 148 passengers or 6 crew members.
 DESCRIPTION OF THE INCIDENT

After take-off, the flight crew detected a "strange smell" in the flight deck which was followed
by a corresponding call from the senior cabin crew and then by the further information that
a "smoke-like effect" had been experienced in the aft cabin after take-off although it had
subsequently cleared. ATC permission to enter a temporary holding pattern whilst a further cabin
assessment was made was obtained. A cabin report was then received advising that, although the
smell had dissipated, it was still present and as it then also seemed to be getting worse again in
the flight deck, it was decided to return to Dublin as a matter of relative urgency. Both pilots
donned their oxygen masks as a precaution, a PAN was declared to ATC due to fumes in the
flight deck and ATC advised the Operator as well as the AFS.

The aircraft landed after 22 minutes airborne and after an expeditious taxi in facilitated by ATC
reached the gate 4½ minutes later. No Operator personnel were available to position the air
bridge and since the aircraft was not fitted with integral air stairs, opening of dis-armed doors
was not permitted under Standard Operating Procedures (SOPs). Concerned at the non-
appearance of operator personnel and in the light of cabin crew concern to "get the (cabin) doors
open straight away, to get some fresh air", the flight crew contacted their Company to stress the
need to attend which eventually occurred. By the time the forward door was opened, the
Operator subsequently reported that the smell/fumes in the cabin were such that "many
passengers had (their) mouths covered with items of clothing and handkerchiefs”.

No passengers or crew required medical attention on disembarkation and medical examination of

all crew members including blood and lung function tests "resulted in no adverse findings".
Thereafter "there were no subsequent reports of associated illness from any of the Crew
Members involved or from any of the passengers".

INVESTIGATION

• The Investigation found that overnight prior to the early morning departure of the
occurrence flight, both of the aircraft's CFM 56-5B4/3 engines had been routinely
pressure washed. The Operator scheduled this non-mandatory task every 1,500 flight
hours.

• The pressure wash task is specified in the AFM and was carried out by two licensed
engineers. Both engineers had previously carried it out - although not specifically trained
for it. The purpose of this post-wash ground run was "to ensure that the bleed system is
free from contaminants.
• The Engineer had never used a corrosion inhibitor before but had read in the AMM that
the corrosion inhibitor was to be added to the oil tanks of each engine. He poured one
can of inhibitor into each of the two water-filled tanks of the wash rig. Engineer who had
least experience of carrying out the task would man the rig required to accomplish it. His
colleague was not present "as he was carrying out other preparatory tasks on the
aircraft/engines"

• The engineer who had made the error became aware of media reports about an air
turnback. He contacted his colleague and told him it may have been caused by a
water/inhibitor mix. The other engineer then realised the inhibitor had been placed in the
wash rig tanks.

• Once the cause of the event had been identified, the Engine Manufacturer was consulted
for guidance. Air conditioning recirculation filters and the avionic equipment cooling air
filter were replaced. Following release to service "repetitive visual inspections of the
engines and the master chip detectors" were scheduled to be performed every 50 to 75
flight hours.

• The Investigation noted that in accordance with mandatory requirements, the Operator's
maintenance personnel had received Company Procedure/Continuation and Human
Factors training. The Human Factors element of this training "referred to the Dirty Dozen
factors" which have been identified as affecting human performance.
 • Corrosion inhibitor involved in contamination was insoluble in water. The fact that the
corrosion inhibitor was used at all was found to be unnecessary. An amendment to the
CFM's AMM has now been taken after the incident.

• The delay in positioning the air bridge to the aircraft given the need to get its occupants
clear was also examined. The Airport Authority stated that the parking gate to be used by
the returning aircraft had been allocated "approximately five minutes before the aircraft
landed"

PROBABLE CAUSE

The occurrence was "the presence of corrosion inhibitor in the Intermediate Pressure (IP) bleed
ducts and IP engine bleed ducts following an engine wash procedure, leading to contamination of
the air conditioning system".

Three Contributory Factors were also identified as follows:

1. Corrosion inhibitor was erroneously added to the water tanks of the engine wash rig.
2. The Operator did not have an engine wash training programme in place prior to the
occurrence and therefore neither Engineer had received training in engine wash
procedures.
3. The alternative post engine wash test did not result in any adverse findings; this test was
only applicable if the engines were washed with pure water.

SAFETY ACTION

As a result of the occurrence included the following by the Aircraft Operator, both of which
meant that Safety Recommendations were not made in either regard:
• An engine wash training programme for its engineers was developed and introduced and
the circumstances of the investigated event were added to their engineers' Human Factors
Training.
• A review of the delay in positioning the air bridge was followed by action to "enhance the
efficacy of their response to aircraft returning due to fumes or other situations where a
prompt disembarkation would be desirable".

SUMMARY

On 3 October 2015, an Airbus A320 which had just taken off from Dublin experienced fumes
from the air conditioning system in both flight deck and cabin. A 'PAN' was declared and the
aircraft returned with both pilots making precautionary use of their oxygen masks. The
Investigation found that routine engine pressure washes carried out prior to departure have been
incorrectly performed and a contaminant was introduced into the bleed air supply to the air
conditioning system as a result. The context for the error was found to be the absence of any
engine wash procedure training for the Operator's engineers.

Event Details

When October 2015

Actual or Potential
Event Type Airworthiness, Fire Smoke and Fumes

Day/Night Not Recorded

Flight Conditions Not Recorded

Flight Details
Aircraft AIRBUS A-320

Operator

Domicile

Type of Flight Public Transport (Passenger)

Origin Dublin Airport

Intended Destination Munich Airport

Take off Commenced Yes

Flight Airborne Yes

Flight Completed No

Flight Phase Climb

ICL / ENR

Location - Airport

Airport vicinity Dublin Airport

FIRE

Tag(s) Non-Fire Fumes

EPR

Tag(s) PAN declaration

CS

Tag(s) Cabin air contamination

 AW

Air Conditioning and Pressurisation,

System(s) Engine - General,

Bleed Air

Maintenance Error (valid guidance available),

Contributor(s)
Engine Compressor Washing

Outcome

Damage or injury No