B767-300 and 300 ER
Communication Breakdown; Training / Qualification; Situational Awareness; Physiological - Other; Distraction; Troubleshooting
Aircraft Equipment Problem Critical; Deviation / Discrepancy - Procedural Maintenance; Deviation / Discrepancy - Procedural Published Material / Policy; Flight Deck / Cabin / Aircraft Event Illness / Injury
General Flight Cancelled / Delayed; General Maintenance Action; General Physical Injury / Incapacitation; General Release Refused / Aircraft Not Accepted
Aircraft; Company Policy; Human Factors; Procedure
I arrived at the gate for a flight. Inquiring as to any info the flight crew might need from the agents I was informed that our flight was delayed 30 minutes from its early afternoon scheduled departure; no reason for the delay was given or known. Upon arriving at the aircraft I was informed that all the lavatories had inoperative stickers on the sinks and all the doors to the water valves had been left open. No maintenance personnel where present at that time. Having checked the aircraft record prior to flight I did remember seeing a write up about the lavatories but that was all I remembered. At that time there where five crew members present: two pilots and three flight attendants. One [was] in the first class galley and two in the aft. The Relief Pilot was in the process of doing his preflight and I had been looking into the lavatory issue. At some point I asked our First Class Galley Flight Attendant about coffee. After attempting to make my coffee I discovered that the milk seemed to have separated. Without tasting it I smelled an odd odor; tossing it out I made a second up with half and half. Taking a sip I immediately tasted an odd chemical taste. Spitting out the coffee into the sink was the smartest thing I could have done. Dispensing a small amount of water into a cup we observed it to be a green color. We then called the rear flight attendants and told them not to drink or use the water. What we did not know was they had already drunk coffee and used the water to make oatmeal. At this point I called the Ramp Manager to find out what they knew. He arrived at the aircraft; was shown the water then he left. His responsibility seemed to have ended at this point as we never heard from him again. I then found the log book on the desk at the jet bridge. Reading the book and a checklist within I discovered the aircraft was out of service for a water system flush with a chemical used to kill bacteria within the water system. I also found that the aircraft had its water system placarded three days ago for failing the EPA water test. At some point two mechanics appeared. They asked what we were doing on the aircraft and why we were getting the plane ready. We were informed that the aircraft was not in service and that no one was to have been allowed on the aircraft. After a lengthy discussion as to what was happening it was determined that the aircraft was taken off the earlier flight due to the lengthy process of flushing the water system. We were also informed that no one was to have been at or on the aircraft. We were told that the fluid involved in killing the bacteria was toxic and at no point should have anyone outside of the two mechanics working on the aircraft been allowed on it. At some point I called Chief Pilot. Informing him of the situation he said he would make a call. In retrospect he should have come immediately to the gate to find out what was happening. Instead a much less informed Maintenance Supervisor showed up. After a great deal of apology he too left never to be seen again.  After a lengthy process of acquiring information this is what we found. The work being done had never been accomplished at the gate. The process of flushing and testing is a lengthy one. Not meant for anyone but those working on the aircraft to have access too. There is no way to predict when this process would be completed. The toxic nature of this process and its length should have been relegated to an over night hangar action. Two flight attendants and one pilot had consumed unknown quantities of the fluid. One Flight Attendant was sent to the emergency room with several problems. One was treated at company medical. All the flight attendants had been removed from the flight. The flight crew was never contacted even though we had been exposed. As for my health I have been suffering from a continuous headache for over 48 hours. The next morning I felt uneasy and achy. Beyond the mechanics no one knew what was going on. Ramp Tower at one point wanted to know why we had not boarded; remember the Ramp Manager had been called to the aircraft. Crew Tracking nor Dispatch knew the aircraft was not in service. Repeated attempts to get a new aircraft seemed to have fallen on deaf ears. No attempt was made to block access to the aircraft. Most likely due to the fact that the two mechanics believed that the crew would have been told the aircraft was out of service. Bottom line; this process should never have been done at the gate. The risk is too great that someone with access could ingest water from the system. No effort was made to inform the crew; agents; Ramp Tower; Crew Tracking; or Dispatch. To sum it up this is a clear case of safety being thrown out for saving a few dollars. The process has no known end point. Simply put they keep flushing the system until the disinfectant is gone. The result was a delay of over four hours. Three crew members exposed to a toxic fluid [and] countless passengers where delayed and disenfranchised. We need to ask to what end did this serve? This procedure should never be accomplished at the gate. Access should be restricted; a sign should appear at the aircraft entry.
The Reporter stated that he learned after the trip that other aircraft were serviced with contaminated water because the area's water treatment systems were inundated with storm water. This aircraft had been serviced at an airport; flown a trip and then arrived at a Company Maintenance Station where the EPA Decontamination Procedure had been scheduled. He was told that normally the water decontamination procedure is accomplished at the hangar but because of a mechanic personnel shortage a Company policy shifted as much work as possible to the line mechanics. In this case a complete maintenance system's failure allowed crew access to the aircraft when no access should have been allowed because the aircraft was removed from service and was under going the second decontamination procedure of the day. Apparently the only person with knowledge about the aircraft's status was the Ramp Manager and he failed to notify Dispatch; gate agents; Scheduling and others in the management chain about the aircraft's status. The Reporter stated that even the simple process of installation caution or no access tape in the jetway would have prevented one Flight Attendant from having her stomach pumped and the others being removed from the trip. The Reporter had a headache for about two days but did complete this trip.
Entire flight attendant crew went to company medical and called in sick. No spare aircraft was available. Decontamination process was completed three and a half hours after scheduled departure as replacement flight attendant crew began arriving. Why was a 10 hour procedure scheduled on an aircraft with a 4 hour turn-around?
A B767 crew became ill after ingesting water tank cleaning fluid during preflight because the aircraft and its water systems were not completely inaccessible during an EPA mandated water tank bacterial decontamination procedure.