Serious incident Avro RJ100 HB-IYU, Saturday 3 September 2016
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Date:Saturday 3 September 2016
Time:c. 14:00 UTC
Type:Silhouette image of generic RJ1H model; specific model in this crash may look slightly different    
Avro RJ100
Owner/operator:Swiss
Registration: HB-IYU
MSN: E3379
Year of manufacture:2000
Fatalities:Fatalities: 0 / Occupants: 92
Other fatalities:0
Aircraft damage: None
Category:Serious incident
Location:8 NM west of waypoint DOPIL -   Switzerland
Phase: En route
Nature:Passenger - Scheduled
Departure airport:Genève-Cointrin Airport (GVA/LSGG)
Destination airport:Zürich-Kloten Airport (ZRH/LSZH)
Investigating agency: STSB
Confidence Rating: Accident investigation report completed and information captured
Narrative:
The Avro RJ100 aircraft, registered as HB-IYU, took off from Geneva with the radio call sign SWR48TP at 13:58 UTC for the scheduled flight LX 2813 to Zurich. There were 2 pilots, 2 cabin crew members and 88 passengers on board. The pilot was the pilot monitoring (PM) and the co-pilot was the pilot flying (PF).
Whilst on the ground, bleed air from the auxiliary power unit (APU) had been activated to cool down the cabin air.
After take-off, at 1,500 ft above ground level (AGL), the engines were set to climb power and clean up was initiated. As per the relevant checklist, engine bleed air was now activated for the air onditioning system and the APU was switched off. Shortly afterwards, the crew noticed a fume smell. They therefore wanted to return to the initial configuration using APU bleed air.
As the APU had already been switched off, it was restarted; this start-up was unsuccessful and the APU only started at the second attempt. In the meantime, the crew had switched off the engine bleed air as they wanted to prevent further air contamination. Shortly after switching off the engine bleed air, the co-pilot already noticed a slight improvement in the air quality. This view was not shared by the pilot.
After the successful start-up of the APU, the APU bleed air was reactivated and the flight crew immediately judged the air quality to be significantly better. Subsequently, at 14:06 UTC, the pilot requested the senior cabin crew member to come to the cockpit. he reported that the cabin air was fine and that he could not smell anything abnormal in the cockpit.

The flight crew subsequently decided to put on their oxygen masks for safety reasons and did so at 14:17 UTC. Furthermore, they decided to request priority for the approach to and landing in Zurich.
A safe landing was carried out at 14:28 UTC.

After the flight, the two pilots went to the Airport Medical Centre (AMC) for a medical check-up. The main reason for this was that the co-pilot was experiencing a severe headache and an extremely sore throat.
Both pilots were examined at the AMC. These examinations did not produce any causal findings that could definitively have pointed towards an exogenous intoxication as described by the pilots.
Over the course of the following days, both pilots reported to their Aviation Medical Examiners (AME). The pilot was signed off as healthy within a short period of time and was certified as fit to fly on 4 th September 2016. The co-pilot had a somewhat longer recovery period and did not return to flying activities until 14th September 2016.

STSB Analysis and conclusions
After take-off, a fume smell became noticeable when the air supply was switched to engine bleed air. The flight crew immediately turned off the engine bleed air and, after the APU had been restarted, again supplied the air conditioning packs with its bleed air. These actions were appropriate for the situation and both logical and justified, as the APU bleed air had conditioned the cabin’s air on the ground without any problems. It was not foreseeable that the fume smell would return after a certain period of time.
When the fume smell again became noticeable and also had physical effects on the flight crew, they immediately put on their oxygen masks. This behaviour was safety-conscious. Involving the cabin crew in the assessment of the situation and repeatedly enquiring about the air quality in the cabin was prudent.
However, the serious incident has once again demonstrated that it is virtually impossible to either identify the source of the contaminated air or to predict its further development. Therefore, flight crews would be well-advised to classify any occurrence of contaminated air that requires oxygen masks to be put on as an emergency and to act accordingly.

Accident investigation:
cover
  
Investigating agency: STSB
Report number: 
Status: Investigation completed
Duration: 6 years and 6 months
Download report: Final report

Sources:

https://www.sust.admin.ch/inhalte/AV-berichte/HB-IYU_sumB_e.pdf

History of this aircraft

Other occurrences involving this aircraft

18 August 2007 HB-IYU Swiss European Air Lines 0 London City Airport (LCY) sub
Runway mishap

Revision history:

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