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ASN Wikibase Occurrence # 193648
Last updated: 25 February 2017
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Date:03-OCT-2015
Time:06:40
Type:Silhouette image of generic A320 model; specific model in this crash may look slightly different
Airbus A320-214
Owner/operator:Aer Lingus
Registration: EI-DVJ
C/n / msn: 3857
Fatalities:Fatalities: 0 / Occupants: 154
Other fatalities:0
Airplane damage: None
Category:Incident
Location:near Dublin Airport (DUB/EIDW) -   Ireland
Phase: Initial climb
Nature:International Scheduled Passenger
Departure airport:Dublin Airport (DUB/EIDW)
Destination airport:München-Franz Josef Strauss Airport (MUC/EDDM)
Investigating agency: Air Accident Investigation Unit (AAIU) - Ireland
Narrative:
Immediately after take-off from Dublin Airport, at approximately 06.40 hrs, the flight crew detected a "strange smell" in the aircraft cockpit. This was followed by a call from the Senior Cabin
Crew Member (SCCM) to advise that there was an "extremely bad fumy smell in the cabin straight after take-off". There were no cockpit warnings or indications of a malfunction. The commander, who was the Pilot Flying (PF), switched the pack flow (air conditioning system) to HI (high). However, the smell was still apparent in the cockpit. He spoke again with the SCCM, who informed him that there was some improvement in the cabin. The commander advised the SCCM that there had been some maintenance performed on the aircraft and that the smell may be connected to that, or to a previous de-icing process performed on the aircraft. He confirmed that the SCCM was feeling okay and asked her to check if the cabin crew members at the rear of the aircraft had noticed anything. She said she would report back. The flight crew noticed a reduction in the intensity of the smell at this time. A short time later, the SCCM reported back to the commander, stating that the crew at the rear of the aircraft had noticed a "smoke-like effect" in the cabin after take-off, which had since cleared. The SCCM said a smell was apparent in the rear galleys, but that it had reduced in intensity. The commander told the SCCM that he could no longer smell anything unusual in the cockpit, but that the co-pilot, who was the Pilot Monitoring (PM), could. The commander advised the SCCM that because the smell was still present, he would "go back into Dublin". The SCCM asked if she could carry out a further inspection of the passenger cabin before the decision to return to Dublin was made. At this point, the flight crew informed ATC of a "slight problem here in the cabin" and requested to enter a holding pattern. Following the SCCM’s re-inspection of the cabin, she informed the commander that the smell was still noticeable, but that it had "dissipated". The commander, having alreadydiscussed the possibility with the co-pilot, informed the SCCM that the aircraft would return to Dublin. A briefing was given to the SCCM for the return to Dublin Airport, which was expected to take approximately 10 minutes. The SCCM was advised that a normal landingwas planned.
The commander made a PA to the passengers, advising them of the situation. At this point, he noticed that the smell was becoming worse and instructed the co-pilot to declare a PAN to ATC, reporting that "we have some fumes coming through into the cockpit". Following the receipt of the PAN declaration, ATC granted an immediate descent and notified the Airport Fire Services (AFS) and the operator. The flight crew donned their oxygen masks and carried out the initial items from the ‘SMOKE/FUMES/AVNCS SMOKE’ checklist in the Quick Reference Handbook (QRH), which includes the requirement to use the crew oxygen masks if necessary. The commander advised the SCCM that both he and the co-pilot had donned their oxygen masks as a precaution and confirmed again with the SCCM that all was okay in the cabin.
A normal landing was performed at Dublin Airport at approximately 07:02 hrs. An expeditious taxi had been requested by the flight crew when the aircraft was on the approach and this was facilitated by ATC, with the AFS providing an escort. As the aircraft taxied towards the parking stand, the flight crew made radio contact with the Operator’s Station Controller, to request the presence of ground staff to assist on arrival. This request was acknowledged.
When the aircraft was on the parking stand, approximately one and a half minutes later, at approximately 07.08 hrs, the flight crew noticed that there was no one at the air bridge. Atthe same time, the SCCM made contact with the flight crew and advised of the need to "get the [cabin] doors open straight away, to get some fresh air". The commander informed her that they were awaiting the air bridge. The flight crew then made several further requests to the Operator’s Station Controller for the air bridge, one of which highlighted the presence of fumes on board. The SCCM contacted the flight crew again to ask if the door could be opened a little, advising that it was "very fumy".
The positioning of the air bridge at the aircraft commenced a short time later, at around 07.11 hrs, approximately three minutes after arrival on stand. Once the air bridge was in position, the forward passenger door was opened and the passengers disembarked the aircraft. The operator reported that the smell/fumes in the cabin were such "that by disembarkation, many passengers had [their] mouths covered with items of clothing and handkerchiefs".

Probable Cause
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.
Contributory Factors
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 program 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.

Sources:

http://www.aaiu.ie/node/1033

Official accident investigation report
cover
investigating agency: Air Accident Investigation Unit (AAIU) - Ireland
report status: Final
report number: 2017-003
report released:14 February 2017
duration of investigation: 1 year and 5 months
download report: 2017-003

Revision history:

Date/timeContributorUpdates
16-Feb-2017 18:49 harro Added
16-Feb-2017 18:56 harro Updated [Source]

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