National Jet Systems’ cabin air quality events procedure focused on the recording/reporting of odours, post-flight care of crew and maintenance actions. However, it did not consider the possible application of the smoke/fumes procedure, or incapacitation procedure. As a result, there was an increased risk of flight crew being adversely affected by such an event during a critical stage of flight.
The ATSB acknowledges the changes to the maintenance program to reduce the chance of future cabin air quality events.
The additional training components in response to safety issue AO-2023-026-SI-02 also mitigate this safety issue and address the risk of crews being adversely affected by future cabin air quality events during a critical stage of flight. The requirement for flight crews to demonstrate and practise supplemental oxygen use during landing, combined with in‑seat instruction specific to flight crew incapacitation, addresses the safety issue.
National Jet Systems issued a Safety Alert Notice (NJS-SAN-2023-018) immediately after the incident (16 June 2023) reminding flight crews of the insidious nature of pilot incapacitation from fumes and to consider supplemental oxygen as an immediate option to help prevent cognitive impairment.
National Jet Systems also made the following changes to their maintenance program to reduce the likelihood of future cabin air quality events:
