The Charity
Aviation
Maritime
I took over an aircraft in [Base] for a double [Station] (operating out of base, normally I am [2nd Station] based). Off going captain reported to me that in [3rd Station] they had had a ‘smoke event’. They told me that once the doors were armed, with the APU on and one PACK on, they received a call from the CM that there was smoke in the cabin. The captain told me that they opened the flight deck door and was ‘shocked’ by how much smoke was in the cabin. They put the second PACK on and turned the flow to hi and the smoke dissipated. The captain called [Maintenance Control] who told them to fill in a ‘smell form’ but DON’T put it in the tech log. The crew did as they were told and operated back to [Base].
After learning this information, I called [Maintenance Control] once the first officer arrived and told them I wouldn’t be accepting the aircraft until there was an engineering inspection and that I was entering an open defect in the tech log. This was agreed and the engineers did an APU inspection, PACK burn and checked the avionics bay. The aircraft was released to service. As it happens, we didn’t use the aircraft as we were swapped onto a different one for operational reasons.
My concern and why I’m raising a CHIRP report is firstly that [Maintenance Control] told the crew not to open a defect in the tech log, why? Our Ops Manual states that if a ‘smell event form’ is filled in then a ‘tech log entry is required’. This to me feels like commercial pressure; [Maintenance Control] know that there will be an extended delay due to the time it takes to investigate these types of events. I subsequently found out the aircraft had a ‘significant maintenance input planned for that night and needed to be back in [Base]. Was this a factor in the decision making? What if I hadn’t seen the off going captain? How would I have known that this potentially serious event had occurred? Secondly, I think there is complacency across the industry when it comes to smell, fume, smoke events. Anecdotally on the line I have heard of multiple crews having these types of events in flight and not using oxygen. The AAIB have investigated multiple events where masks were not used. BALPA have published articles about the risks of not taking these events seriously. The message is not getting through.
This is a very useful report and we’re grateful to the reporter for highlighting this concerning drift into poor practice, which appears to be an example of normalisation of deviance. It’s not clear why the captain didn’t use the tech log to record the fumes event. Perhaps there was a lack of trust in the operator’s safety culture and this particular captain was keen not to rock the boat? Or maybe the legal requirements of tech log use weren’t understood. Alternatively, the captain may have been put under pressure by Maintenance Control not to report and went along with it. It takes courage to do the right thing, especially if this could be erroneously viewed as ‘unhelpful’. If this deviation was led by Maintenance Control, it’s not clear why they wouldn’t want the event formally recorded. As the reporter says, it could have been commercial pressure, or perhaps it was complacency because fume/odour events are such a common feature on some aircraft types.
Whatever the background on this occasion, the bottom line is that it is always the responsibility of the aircraft captain to ensure that all defects are recorded in the tech log. This responsibility should never be verbally ‘handed on’ to the next captain or left, without formal record, with Maintenance Control. A smoke event could be a precursor to something even more serious, therefore following the correct procedure is especially important in these circumstances.
Communication is one of the Dirty Dozen and a key Human Factor consideration. Communication is not just limited to the contents in Chapter 23, it is verbal, written, printed, hand signals, lights, oral warnings, bells and horns, megaphones, smells and other physical sensations. Not using the tech log takes us back to the days of recording defects on a discarded cigarette packet. Are we not better than that nowadays?