Teamsters Air Quality Reporting Form

Like many airline crewmembers around the world, Teamster members are concerned with the air quality aboard commercial aircraft. These concerns have arisen in part because of the increasing number of unusually debilitating health problems experienced by crewmembers while working. On occasion, passengers have reported similar problems. The Teamsters Airline Division and your local unions, along with other flight attendant unions worldwide, are working together on this important issue.

As part of this collaborative effort, we are participating in an air quality incident data collection initiative sponsored by the International Transport Workers Federation (ITF). Other U.S. flight attendant unions participating in this effort include: Association of Flight Attendants (AFA), Transport Workers Union (TWU), and International Association of Machinists (IAM). The database will be used to document the frequency and nature of air quality incidents. This information is necessary to identify causes of air quality problems, to suggest possible solutions, and to seek legislative and/or regulatory remedies to protect crew and passengers.

We have adopted the ITF data collection form and made it available on our web site. It is also available in paper form from the Airline Division office. Information you provide about an air quality incident will become part of the ITF database (as well as a Teamster database). However, all data will be de-identified prior to being forwarded to the ITF. Your personal information and identification will remain confidential. If you have any questions about participating in the air quality database, please call the Airline Division office. To report an incident, please fill out the form below.

You Are? Cabin Crew/Flight Attendant

Pilot

Mechanic

Other:

Your Name:

Date of Incident: (ex: mm/dd/yy)

Phone Number: () -

Name of Airline:

E-Mail:

Mailing Address:

State:

Do you think this incident could have been prevented?

Yes

No

Question 2.) Cabin Crew/Flight Attendants, Pilots, and Mechanics, please complete; others please skip to question 3.

Name of Union:

Local Union Number:

Base:

Base Other:

Years of work experience:

Number of hours on duty before incident:

Did you file a workers comp/industrial injury claim?

Yes pending

Yes denied

Yes approved

No

Don't know

Did you file a report with the company?

Yes

No

To your knowledge, did this incident affect passengers?

Yes

No

Don't know

To your knowledge, did this incident affect another member(s) of the crew?

Yes

No

Don't know

Question 3.) If incident happened ON the aircraft, answer these and then continue with Question 4.

Type of aircraft:

Flight Number:

Aircraft Tail Number:

Origin:

Origin Other:

Destination:

Destination Other:

Did flight continue?

Yes

No

Passenger Load:

0-25%

25-50%

50-70%

70-100%

Flight duration hours:

Number of Cabin Crew/Flight Attendants on Duty:

Number of Cabin Crew/Flight Attendants Required:

Incident Location in Aircraft:

Rear

Middle

Forward

All

Cabin

Galley

Lavatory

Cockpit

Crew Rest

Other:

Flight Phase:

Boarding

Engine start up

Taxi out

Climb

Cruise

Descent

Landing

Deplaning

All

Other:

Did you see a smoke or Mist?

Yes

No

Did you notice an odor?

Yes

No

If you answered "yes" to an odor and/or smoke/mist, how long did it last?

If there was an odor, select ONE phrase that describes it BEST.

Cigarette smoke

Burning smell

Deicing fluid

"Dirty socks"

Electrical smell

Engine exhaust

Lavatory cleaners/Blue fluid

Lavatory waste

Oil/fuel

Pesticides

Sweet smell

Unknown

If OTHER, describe below:

Did you notice a problem with the temperature of the cabin?

Too hot

Too cold

No problem noticed

Question 4.) Describe what happened in your own words.

Did you feel like the air was fresh enough in cabin?

Yes

No

Don't know

Question 5.) For pesticide problems please answer these questions. Other wise, go to question 6.

Do you know when the aircraft was last treated?

Was this problem with...

Residual spraying (Pre-boarding)

In-flight spraying (Pre-deplaning)

Don't know

Were the walls/seats/surfaces wet to touch?

Yes

No

Don't know

Was crew rest area wet or damp?

Yes

No

Don't know

Was the crew rest area dry but problematic?

Yes

No

Don't know

Question 6.) If you experienced any symptoms, please indicate which ones.

NO SYMPTOMS NOTICED

Allergic reaction

Breathing difficulty

Coughing

Dizziness/fainting

Ear inflammation/blockage/damage

Eye irritation

Fatigue

Headache

Heartbeat rapid/chest pain

Impaired vision

Inability/reduced ability to perform duties

Infectious agent

Loss of balance/disorientation

Memory loss

Metallic taste

Muscle tremors/twitching

Nausea

Nose bleed

Sinus problem

Skin irritation/rash

Throat irritation

Vomiting

Other:

Did you notice related medical problems BEFORE the flight?

Yes

No

Don't know

If yes specify:

Did you notice these symptoms DURING the flight?

Yes

No

Don't know

If yes specify:

Did you receive medical attention (including oxygen) DURING your shift/flight?

Yes

No

Did you notice these symptoms AFTER the flight?

Yes

No

Did you seek medical attention AFTER the flight?

Yes

No

Question 7.) For certain types of air quality incidents, the following technical information might be relevant. If possible, please obtain this information. If not available, just submit your report.

Aircraft Number/Registration:

Had plane been deiced?

Yes

No

Don't know

Captain:

Base:

Base Other:

First Officer:

Base:

Base Other:

Captain experienced symptoms?

Yes

No

Don't know

First Officer experienced symptoms?

Yes

No

Don't know

If either reported symptoms, please describe them:

Flight report submitted?

Yes

No

Don't know

Maintenance log entry completed?

Yes

No

Don't know

If yes Maintenance log entry number::

Hydraulic fluid gauge reading:

Oil gauge reading:

Conditions During Incident:

Number of air packs in use:

Number of air packs available:

Were any of the packs inoperative?

Yes

No

Don't know

Source of supply air:

APU

Engine

Don't know

Recirculating fans:

On

Off

Don't know

Cabin altitude:

Actual altitude:

Supply duct temperature:

Degrees Fahrenheit

Degrees Celsius

Left side:

Right side:

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