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NTSB Report

December 20, 2008 · Boeing 737-4Q8 · N771AS

Sitka, AK

Overview

Report Status
Final with probable cause
Event Type
Incident
Date
December 20, 2008
Injury Outcomes
88 injuries (88 minor injuries)
Location
Sitka, AK
Aircraft
Boeing 737-4Q8
Tail Number
N771AS
Operator
Alaska Airlines
Injuries
Minor
NTSB Number
ANC09IA015

After departure the cabin crew reported to the captain that they were becoming nauseated. The captain noted that the departure was the first flight of the day and that the airplane had been sitting on the ramp overnight connected to an external heating unit. He said that prior to flight the first officer and cabin crew went to prepare the airplane while he remained in the operations center with paperwork. He said the first officer requested the ground crew shutdown the external heater because of exhaust fumes in the airplane's cabin. The first officer started the airplane's auxiliary power unit to provide power and heat to the airplane. The captain said that about 15 minutes later he did not detect any unusual smells or odors, and wiped his hand across seats and surfaces to detect contamination. Finding none, he felt it was safe to continue boarding. He reported that the boarding process was normal, and none of the crew or passengers reported any unusual smells or odors. When the cabin crew reported feeling nauseated, the captain determined that they were 20 minutes from their destination and decided to continue the flight rather than turn back. The captain reported that he and the first officer were symptom free, and that the first officer remained on oxygen for the remainder of the flight as a precaution. Upon arrival the flight crew all tested positive for elevated levels of carbon monoxide. The cabin of the airplane was examined and no traces of carbon monoxide were found. Tests of the ground heating unit found no anomalies, and the heat output hose was tested for CO with negative results. According to the director of safety for the operator, the contamination probably occurred when the morning ground crew started the push-back unit in the proximity of the heater's fresh air intake. As a result, the heating unit has been repositioned away from other operating equipment, and a 20-foot exhaust hose attached. Carbon monoxide detectors are now placed in the operator's aircraft during extended external heater usage.

NTSB Probable Cause

The placement of operating equipment in close proximity to an external heating unit's intake by ground personnel, resulting in the contamination of the airplane's cabin with carbon monoxide.

Full Narrative

On December 20, 2008, about 0747 Alaska standard time, the cabin crew of Alaska Airlines Flight 73, N771AS, a Boeing 737, reported to the captain that they became nauseated after departing from Sitka, Alaska. The flight was being operated by Alaska Airlines, Seattle, Washington, as an instrument flight rules (IFR) passenger flight under Title 14, CFR Part 121, when the event occurred. The flight departed Sitka for Juneau, Alaska about 0710, and an instrument flight plan was filed and activated. During a telephone conversation with the National Transportation Safety Board (NTSB) investigator-in-charge (IIC) on December 21, the acting director of flight safety for the operator said he requested a written report from the Captain, and that he was en route to Sitka to investigate the event. The IIC discussed with the acting director testing the external heater for leaks, and the placement of other equipment near the heaters air intake. He said he would report back to the IIC after assessing the situation. In a written statement submitted to the NTSB on December 22, the captain reported that on the morning of the event the crew met early, as the departure from Sitka was the first flight of the day. The airplane had been sitting on the ramp overnight and was connected to an external heating unit. The captain said the first officer and cabin crew went to prepare the airplane while he remained in the operations center to complete the required paperwork for the day's flights. He said he overheard the first officer request the ground crew shutdown the external heater because of exhaust fumes in the airplane's cabin and the jetway. The captain wrote that the first officer remained on the flightdeck long enough to start the airplane's auxiliary power unit (APU) to provide power and heat to the airplane. The first officer and cabin crew returned to the operations center. The captain said about 15 minutes later he went to the airplane to evaluate the condition of the airplane. He said he tried to be cognizant of unusual smells/odors, and wiped his hand across seats and surfaces to detect contamination. Finding none, he felt it was safe to continue boarding for the flight. He reported that the boarding process was normal, and none the crew or passengers reported any unusual smells/odors. After departure the captain reported that the cabin crew reported feeling nauseated. The captain said he consulted with the cabin crew and first officer, and determined that since they were 20 minutes from their destination (Juneau) he would continue the flight rather than turn back to Sitka. The captain reported that he and the first officer were symptom free, and that the first officer remained on oxygen for the remainder of the flight as a precaution. Upon arrival at Juneau the flight crew and one passenger, an off-duty airline employee, were taken to the local hospital to be tested for carbon monoxide (CO). The captain said he was told that the normal levels for carbon monoxide in the blood are 0.0-0.08 percent. He reported that the crew's levels were from 1.8 percent to 4.7 percent. According to the Center for Disease Control (CDC), elevated levels of carbon monoxide in the blood of 2.0 percent for non-smokers and 9.0 percent for smokers, can support a diagnosis of carbon monoxide poisoning. About an hour after landing the cabin of the airplane was examined by the fire department, and no traces of carbon monoxide were found. On February 27, 2009, the acting director submitted his findings to the IIC. Tests of the heating unit found no anomalies, and the heat output hose was tested for the presences of CO, with negative results. He said he believed the contamination occurred when the morning ground crew started the push-back unit in the proximity of the heater's fresh air intake. , According to the acting director, as a result of this event, the heating unit is now repositioned to the opposite side of the aircraft away form other equipment, and a 20-foot exhaust hose is attached. No other operating equipment is allowed in the vicinity of the heater. Carbon monoxide detectors are now placed in the operator's aircraft during extended external heater usage.

Flight

Event TypeIncident
Event Time02:47 AKST
Nearest AirportSITKA (0nm)
Flight Plan FiledIFR
Flight Plan ActivatedYes
Aircraft FireNo
Aircraft ExplosionNo

Aircraft

AircraftBoeing 737-4Q8
Tail NumberN771AS
Aircraft CategoryAir
OperatorAlaska Airlines
Operating RulePart 121
Engines2
Engine TypeTurbofan
Engine DetailsCfm Intl. · CFM56 SERIES · Turbofan · 2200 | Cfm Intl. · CFM56 SERIES · Turbofan · 2200
Seats149

People & Injuries

Injury Summary88 injuries (88 minor injuries)
Fatal0
Serious0
Minor88
Uninjured0
Total88
Crew 1Age 48 · First Class · None

Conditions

ConditionsVMC
LightNight
WindCalm
Visibility10 sm
CeilingNone
Temperature / Dew Point0 C / 0 C
Altimeter0
Weather SourcePILO

Appendix: Source Data