Flybe E195 near Dublin on Oct 16th 2017, smell of smoke in cockpit due to atmospheric conditions, a number of flights affected

Last Update: December 12, 2018 / 16:23:21 GMT/Zulu time

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Photo of Flybe G-FBEM, Embraer ERJ-195 — Flybe G-FBEM, Embraer ERJ-195 (Photo credit: Anna Zvereva / Flickr / License: CC by-sa)

Incident Facts

Date of incident
Oct 16, 2017

Classification
Incident

Airline
Flybe

Flight number
BE-4521

Departure
Cardiff, United Kingdom

Destination
Dublin, Ireland

Aircraft Registration
G-FBEM

Aircraft Type
Embraer ERJ-195

ICAO Type Designator
E195

A Flybe Embraer ERJ-195, registration G-FBEM performing flight BE-4521 from Cardiff,WL (UK) to Dublin (Ireland), was enroute when the crew reported the smell of smoke in the cockpit. The crew decided to continue the flight to Dublin where the aircraft landed safely. Emergency services did not find any trace of fire, heat or smoke.

National Air Traffic Services (NATS) reported they had to facilitate a number of diversions reporting smoke in the cockpit during the day. The observations were caused by atmospheric conditions with the remnants of Hurricane Ophelia reaching Ireland and affecting parts of Britain. Ophelia was carrying sand from the Sahara as well as smoke from forest fires in Spain and Portugal causing a strangely reddish sky over Britain.

British weather services confirmed Ophelia had picked up sands from the Sahara and smoke from forest fires in Spain and Portugal before reaching Ireland and the UK.

The return flight was cancelled. The occurrence aircraft is still on the ground in Dublin about 14 hours after landing.

On Dec 12th 2018 the AAIU released their final report concluding the probable cause of the serious incident was:

Smell of smoke in the aircraft, necessitating the donning of oxygen masks by the Flight Crew, which compromised crew performance due to communications difficulties and obstructed visibility through the mask lenses.

Contributory Cause(s)

- Smoke from wildfires on the Iberian Peninsula drawn towards Ireland and the United Kingdom.

- Lack of a formal method to notify flight crew of such atmospheric conditions.

- Propensity of the surface of oxygen mask lenses to suffer ‘blooming’.

- Inspection frequency insufficient to detect blooming and environmental contamination on the surface of mask lenses.

The captain (42, ATPL, 6,400 hours total, 366 hours on type) was pilot flying, the first officer (27, CPL, 1,604 hours total, 213 hours on type) pilot monitoring. At Dublin Airport low visibility procedures were in use causing delays. The aircraft was thus sent into a holding pattern at FL070.

The AAIU summarized the following sequence of events:

As the aircraft left the holding pattern at FL70, it entered the top of a cloud layer and the Flight Crew noticed a burning smell, which they described as “sulphurous”. The Commander contacted the Senior Cabin Crew Member (SCCM) to check the status of the cabin. The SCCM, who was seated at the front of the cabin, initially reported that everything appeared normal. However, CCM 3 who was seated at the rear reported a “burning smell” towards the back of the cabin. This was confirmed by CCM 2, who was also seated at the rear. The Commander informed the Co-Pilot that there was a “smell of smoke6 in the cabin”, and both pilots noted that the smell appeared to be getting more intense in the cockpit.

The Flight Crew then donned their oxygen masks and attempted to establish communications with each other. At 07.12 hrs, ATC instructed the aircraft to descend to 5,000 ft. ATC had to repeat this instruction as there was no apparent response from the aircraft. The instruction was responded to by the Commander, as it appeared to him that the Co-Pilot’s oxygen mask microphone had failed. The Commander noted that he did not hear the Co-Pilot’s transmissions through his headset, nor could he hear the Co-Pilot’s intercom transmissions.

The Commander took over radio communications and at time 07.13 hrs declared a ‘State of Urgency’ or PAN-PAN7. Following receipt of this transmission, ATC commenced vectoring the aircraft towards the localiser for the Instrument Landing System approach (ILS) to RWY 10 at EIDW.

At 07.14 hrs, the aircraft was cleared to descend to 4,000 ft. and this was acknowledged by the Co-Pilot, whose oxygen mask microphone now appeared to be functioning again. With the Co-Pilot now able to resume communication with ATC, the Commander took the opportunity to brief the Cabin Crew, stating that the aircraft was on final approach to EIDW, they would be landing in approximately eight minutes, to expect a normal landing, that he had informed ATC of the situation on board, and to await further instructions on landing. The Co-Pilot’s oxygen microphone functioned normally until 07.17 hrs, when an attempted response to ATC by the Co-Pilot was again unsuccessful. From this point, until the aircraft landed, all communications between the aircraft and ATC were carried out by the Commander.

In addition to the difficulties with communication, both pilots experienced restricted visibility through the lens of the smoke goggles due to scratches and an obscuring layer on the lens (Section 1.6.3).

Having declared a PAN-PAN, ATC immediately gave priority to the flight and instructed the aircraft to route directly to point GANET on the final approach to RWY 10. However, the Flight Crew had difficulty programming the FMS to comply with this instruction due to the restricted visibility through the goggles. Therefore, ATC facilitated the Commander’s request for vectors to the final approach. The Approach Controller remained in contact with the aircraft throughout the event, until the aircraft had landed. Due to earlier meteorological conditions at EIDW, the Flight Crew had expected and briefed for a Category 2 approach to RWY 10. However, due to the communication difficulties and restricted vision caused by the smoke goggles, the Commander elected to carry out a Category 1 approach.

In addition, due to the restricted communications and reduced visibility presented to the Flight Crew by the oxygen masks, the approach and landing checklists were conducted by holding the checklist up, pointing to an item and giving a ‘thumbs up’ signal as a means of confirming the item had been actioned and positively checked as completed. Using this method the aircraft was configured early for landing. The Commander noted that he could see the aircraft flight instruments despite the problems with his goggles.

The Commander conducted the ILS approach to RWY 10 with the autopilot engaged. He stated that he acquired the runway visual references at approximately 300 ft above aerodrome level, at which point he disconnected the autopilot and took over manual control of the aircraft for landing.

The aircraft landed on RWY 10 at EIDW at 07.23 hrs, and was met by the Airport Fire Services (AFS), after it cleared the active runway on to Taxiway H2. The AFS informed the Commander that there appeared to be no signs of fire or damage on the exterior of the aircraft.

The Flight Crew removed their oxygen masks and noted that the smell of smoke had reduced. The Commander then asked the Cabin Crew for an assessment of conditions in the cabin and was told that the smell of smoke had reduced. Therefore the Flight Crew requested taxi clearance to their allocated parking position. The aircraft parked on stand 207T at 07.31 hrs, where the passengers disembarked normally.

The AAIU analysed:

The meteorological conditions on the day of the occurrence were such that smoke from wild fires over the Iberian Peninsula was drawn over the east coast of Ireland and the United Kingdom. In the Dublin area the smoke-laden air appears to have been present in the atmosphere, from approximately 7,000 ft to near the surface. It was this air that the subject aircraft entered as it left the holding pattern and began its approach into EIDW.

The Flight Crew were not aware of the possible presence of smoke in the atmosphere; therefore it was reasonable, and prudent, for them to suspect that the smoke they perceived had originated from within the aircraft. Consequently, the Flight Crew took the precautionary actions (as trained for), of donning their oxygen masks and declaring a state of urgency.
Once the oxygen masks were put on by the Flight Crew, they were presented with a new set of problems. The lenses of both the Commander’s and the Co-Pilot’s masks were obscured to the extent that their vision was compromised, and the microphone in the Co-Pilot’s oxygen mask was functioning intermittently.

As part of their training to deal with smoke and fumes on an aircraft in flight, crews are cautioned against removing protective breathing equipment even if the smoke and fumes don’t appear to be hazardous, as there may also be other products of combustion present that could lead to flight crew incapacitation. Therefore, despite the difficulties presented by the oxygen masks, the Commander elected to continue the approach with the masks on, as he had sufficient visibility through the lens of his integrated smoke goggles to see the flight instruments, and also the runway once the aircraft was clear of cloud.

Meteorology

The Investigation notes that, other than obscuration reports in METARs, there are currently no requirements to issue warnings or notices to flight crew concerning the presence, in the atmosphere, of smoke from large fires. The subject flight was not the only one affected by the presence of smoke from the wildfires in Spain and Portugal. The Investigation acknowledges that it is imperative that flight crews carry out the necessary and appropriate safety actions in response to a smoke/fume event. However, information regarding the presence of atmospheric smoke may have been useful to flight crews to assist in assessing the origin of the smoke being detected in flight.

With respect to the flight crew's performance the AAIU analysed:

In addition to dealing with the smell of smoke, that the Flight Crew believed originated on their aircraft, they also had to contend with additional problems that were presented when they donned their oxygen masks, that is, lack of voice communication between the pilots and restricted vision through the lenses of the masks. By using a workaround of hand signals, the Flight Crew demonstrated resourcefulness and the ability to quickly adapt to this new situation, in order to complete the necessary checks and prepare the aircraft for landing.