Jetblue A320 at Portland on Jan 20th 2017 and Jan 21st 2017, fumes injure captain, court confirms causal link
Last Update: August 6, 2020 / 16:36:46 GMT/Zulu time
The aircraft had been dispatched for the flight under minimum equipment list requirements with the APU disabled two days (Jan 18th) earlier. The deactivation of the APU was done after black smoke was observed from the APU after shutdown at the gate. A (third) captain on the previous day (Jan 19th) had already reported an odour in the cabin and produced a tech log entry. However, no maintenance action occurred, both after this flight of Jan 19th and Jan 20th.
The following day the flight crew arrived and found two open smell events noted in the tech log and requested maintenance. However, at Portland the local (contract) maintenance was not permitted to do engine run ups. Thus on request by company maintenance the flight crew attempted to isolate the problem by performing three engine runs prior to scheduled takeoff for their flight B6-1206 to New York JFK,NY (USA) at 06:30L. During the first engine run the then captain of this flight checked the cabin and found the foul odour throughout the cabin, while the first officer, who remained in the cockpit, did not notice any odour. During the second engine run captain (claimant) and first officer, according to court documents:
both smelled a very apparent, choking, burning odor like dirty socks or an oily smell. It was the worst toxic fume event claimant ever experienced as a pilot. Both claimant and the First Officer immediately developed headaches and were coughing and had to leave the airplane to get fresh air. The First Officer also had throat irritation in the form of drymess and hoarseness. Claimant fell down on the jetway and a mechanic ran up the stairs to the plane and said, “Oh my God. There’s a haze in here.” Claimant and the First Officer re-entered the plane for the third engine run and the odor was again very apparent to both of them. The First Officer was still coughing and he had a headache focused on the front of the head and pain was developing behind his right eye as if someone was poking him in the eye. Claimant was coughing, his eyes stung and watered, the right side of his body shook with tremors, and he had mild shortness of breath, headache, and congestion. He also had some ulnar aspect numbness in his forearm and hand that resolved after a couple of days.
Claimant shut the engines down after the third run and instantly opened the flight deck windows to get fresh air. As the jet bridge was reattached, one of the in-flight crew members saw haze in the main cabin. Claimant contacted maintenance control and reported what happened. Maintenance agreed that burning oil probably leaked through an engine seal into the ventilation system. A February 22, 2017 Engineering Disposition Report confirmed that the airplane APU was cracked and leaking oil with oil contamination into the ducting. That report of oil leakage in the engine and ventilation systems was very typical for fume event chemical exposure cases and confirmed a pathway for jet engine oil pyrolysis products to enter the cabin air.
Neither the FAA nor the NTSB list either of the occurrences, no investigation is apparent.
The Workers Compensation Board of the State of Oregon released their opinion and orders on Jul 31st 2020 confirming the captain of the flight had been injured by fumes encountered on board of Jetblue aircraft and a causal link between the fumes and his injuries was proven.
The court orders in his verdict (main orders only):
IT IS HEREBY' ORDERED that JetBlue Airways and AIG - Chartis Claims’ February’ 20, 2019 denial of compensability of claimant’s toxic encephalopathy is set aside (Ex. 113). The claim is remanded to the employer for acceptance and processing according to Oregon workers’ compensation laws.
IT IS FURTHER ORDERED that JetBlue Airways and AIG - Chartis Claims’ April 2, 2019 denial of compensability of claimant’s mild neural cognitive disorder is set aside (Ex. 116). The claim is remanded to the employer for acceptance and processing according to Oregon workers’ compensation laws.
IT IS FURTHER ORDERED that JetBlue Airways and AIG - Chartis Claims' April 2, 2019 denial of compensability of claimant's vision disorders, including convergence insufficiency and saccadic eye movement deficiency, is set aside (Ex. 116). The claim is remanded to the employer for acceptance and processing according to Oregon workers’ compensation laws.
IT IS FURTHER ORDERED that JetBlue Airways and AIG - Chartis Claims’ February 8,2019 denial of compensability of claimant’s “current condition” is set aside (Ex. 110). The claim is remanded to the employer for acceptance and processing according to Oregon workers’ compensation laws.
IT IS FURTHER ORDERED that a causal connection was established between claimant’s compensable injury' and the 24 acupuncture visits recommended by Dr. Ugalde to treat the post traumatic headaches associated with his toxic encephalopathy.
In his "Findings of Facts" the court stated:
The primary explanation for fume events in airplanes is that jet engine oil has been pyrolyzed (heated) at extremely high temperatures and leaked through oil seals before entering the ventilation systems where the fumes are pumped into the cabin environment (Ex. 139-65). When jet engine oil is pyrolyzed, it also produces a complex mixture of new fugitive chemical emissions in addition to Ultrafine Particles (UFPs), which are the same size as Nano-particles, namely 1 - 100 nm (Exs. 141-7 & 141C, pages 4-5). Particles that small become much more reactive, even for materials that are chemically inert in bulk, because they (1) induce inflammation, largely irrespective of what they are made of, (2) are preferentially deposited to the deepest alveolar regions of the lungs, where gas exchanges between air and blood are conducted, and (3) can act like Trojan Horses as they cross the Blood Brain Barrier (BBB), which has evolved to keep unwanted chemicals at bay, thereby avoiding the metabolic defense mechanisms of the BBB while the toxins adhere to the surface of the Nano-particles (Ex. 141C-5).
Mobile Jet Oil II was used in the jet flown by claimant on January 21, 2017 (Claimant & Judith Anderson testimony). That oil was composed of a synthetic base stock of esters and fatty acids with a complex mixture of 250 to 400 chemical compounds and four additive ingredients that improved specific performance characteristics such as oxidation and wear tendencies (Judith Anderson testimony; Ex. 141-16). Those additive ingredients included Tri-cresyl phosphate (TCP) at concentrations from 2-5%, n-phenyl-l-naphthylamine (PAN) at 1%, 9,10- antrhacenedioine, 1,4-dihydroxy- at
Part of the claimant's winning arguments brought forward by his attorney can be seen in this filing.
The airline wrote in their "Weekly Update from your Jetblue Master Executive Council" dated Apr 14th 2017:
The dangers of cockpit fumes has recently taken on a new level of seriousness as one of our pilots has been exposed to these dangerous fumes. In January, Captain ... was exposed to fumes while performing an engine run up at the request of maintenance. As a result of the fumes event, ... has had numerous health problems, been out on medical leave for months, and may never return to the flight deck. We would ask that you keep Captain ... in your thoughts and prayers.
This article is published under license from Avherald.com. © of text by Avherald.com.
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