Oil fumes, flight safety, and the NTSB

Abstract

During its investigations into a series of ten aircraft crashes from 1979 to 1981, US National Transportation Safety Board (NTSB) officials were presented with a hypothesis that “several” of the crashes could have been caused by pilot impairment from breathing oil fumes inflight. The NTSB and their industry partners ultimately dismissed the hypothesis. The authors reviewed the crash reports, the mechanics of the relevant engine oil seals, and some engine bleed air data to consider whether the dismissal was justified. Four of the nine aircraft crash reports include details which are consistent with pilot impairment caused by breathing oil fumes. None of the tests of ground-based bleed air measurements of a subset of oil-based contaminants generated in the engine type on the crashed aircraft reproduced the inflight conditions that the accident investigators had flagged as potentially unsafe. The NTSB’s conclusion that the hypothesis of pilot incapacitation was “completely without validity” was inconsistent with the evidence. Parties with a commercial conflict of interest should not have played a role in the investigation of their products. There is enough evidence that pilots can be impaired by inhaling oil fumes to motivate more stringent design, operation, and reporting regulations to protect safety of flight.