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After boarding the flight in Sydney, the supernumerary pilot had examined the aircraft maintenance release and noted a deferred defect concerning oil residue at the number two air conditioning pack inlet, resulting from an oil leak from the number four engine. This maintenance release entry was dated 17 June 1997. Maintenance trouble-shooting had isolated the problem to a
10  Submission 1, Captain Frank Kolver. Dr Richard Loblay presented an alternative explanation for Captain Kolver’s experience when he told the inquiry: “I do not know whether that particular incident was caused by fumes. It may have been that the pilot smelled something. … where a person is exposed to a smell and believes that that smell might be toxic or dangerous, they can become acutely anxious, hyperventilate and then lose control of their faculties. The symptoms that were described in that particular case suggest to me that the pilot panicked.” Dr Robert Loblay, Evidence, 1 February 2000, p 106.
11  NJS, Evidence, 1 February 2000, p 135
failing oil seal within the number four engine. The aircraft had been cleared for further flight without any operational restrictions being noted, and the defect was listed for rectification at company convenience.
On experiencing the fumes during the descent into Melbourne, the supernumerary pilot recalled that he had noted a defect concerning the number two air conditioning system, and rechecked the maintenance log to determine which bleed air system may have been contributing to the source of contamination.
After shutdown at Melbourne, the crew vacated the aircraft. Following exposure to fresh air for about 30 minutes, the effects of the oil fumes dissipated. As a result, the crew did not consider it necessary to seek medical advice before continuing the scheduled flights. This decision was reinforced by the fact that the co-pilot had not reported being affected by the fumes. The crew further advised that because the technical log already contained an entry regarding the number four engine, and because Maintenance were aware of the problem, another entry regarding the same problem was unnecessary. They elected to continue the remaining scheduled flight sectors with the number four-engine bleed air system turned off, in accordance with the provisions of the master minimum equipment list (MMEL). The remainder of their tour of duty was completed without incident.12
5.16 At the end of this Occurrence Brief BASI stated:
The Bureau of Air Safety Investigation is particularly concerned about the potential for further BAe 146 flight and cabin crew to become incapacitated during flight due to exposure to odours being introduced into the aircraft cabin environment. In this occurrence, two of the three flight crew members on board the aircraft suffered from symptoms that prevented them from properly carrying out their assigned duties. The introduction of fumes and odours into the cabin environment following an engine defect constitutes a possible safety deficiency that should be addressed by the regulatory authority, in accordance with its statutory responsibility to monitor the continued airworthiness of aircraft.
　
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