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Report by the Senate Rural and Regional Affairs and Transport References Committee Parliament of the Commonwealth of Australia Air Safety and Cabin Air Quality in the BAe 146 Aircraft Report by the Senate Rural and Regional Affairs and Transport References Committee OCTOBER 2000 ii © Commonwealth of Australia 2000 ISBN 0 642 71093 7 This document was produced from camera-ready copy prepared by the Senate Rural and Regional Affairs and Transport Legislation Committee, and printed by the Senate Printing Unit, Department of the Senate, Parliament House, Canberra. iii MEMBERS OF THE COMMITTEE Members Senator John Woodley AD, Queensland Chairman Senator Winston Crane LP, Western Australia Deputy Chairman Senator Jeannie Ferris LIB, South Australia Senator Michael Forshaw ALP, New South Wales Senator Sue Mackay ALP, Tasmania Senator Kerry O’Brien ALP, Tasmania Participating Members Senator Abetz Senator Faulkner Senator McLucas Senator Bartlett Senator Ferguson Senator Mason Senator Boswell Senator Gibson Senator S Macdonald Senator Brown Senator Harradine Senator Murphy Senator Buckland Senator Harris Senator Payne Senator Calvert Senator Hutchins Senator Tchen Senator Chapman Senator Knowles Senator Tierney Senator Coonan Senator Lightfoot Senator Watson Senator Crossin Senator McGauran Senator West Senator Eggleston Senator McKiernan Committee Secretariat The Senate Parliament House Canberra ACT 2600 Telephone (02) 6277 3511 Facsimile (02) 6277 5811 Internet www.aph.gov.au/senate Email [email protected] TABLE OF CONTENTS MEMBERS OF THE COMMITTEE ............................................................. iii TABLE OF CONTENTS.................................................................................. iv ABBREVIATIONS ......................................................................................... viii CONDUCT OF THE INQUIRY....................................................................... x EXECUTIVE SUMMARY............................................................................... xi RECOMMENDATIONS................................................................................. xv CHAPTER ONE................................................................................................. 1 INTRODUCTION AND BACKGROUND....................................................................... 1 Introduction – the issues before the Committee ............................................................... 1 Current Applicable Australian Regulatory Requirements – Flying and Airworthiness... 1 Civil Aviation Regulations (CARs) ............................................................................. 1 Federal Aviation Regulations (FARs).......................................................................... 2 Health and Safety Issues .............................................................................................. 2 CHAPTER TWO................................................................................................ 7 THE BAe 146 AND AIR QUALITY................................................................................. 7 The aircraft ....................................................................................................................... 7 Aircraft configuration................................................................................................... 8 Number of BAe 146 aircraft operating in Australia..................................................... 8 Source of air in the BAe 146 cabin................................................................................... 9 Domestic and international laws and standards for the quality of air in aircraft............ 11 BAe 146 cabin air quality problems in Australia ........................................................... 13 Australian Experience ................................................................................................ 13 International experience ............................................................................................. 15 Ansett Australia’s approach ....................................................................................... 19 Incidence of Ansett fume reports ............................................................................... 20 Reluctance to report incidents.................................................................................... 21 Attitude of airlines to staff suffering reactions to fumes............................................ 23 Exemptions for flight crew not to work on BAe 146 aircraft .................................... 24 v CHAPTER THREE ......................................................................................... 29 SYMPTOMS OF ILLNESS AND POSSIBLE SOURCES........................................... 29 Examples of symptoms................................................................................................... 29 Possible enhanced effect on symptoms from flying....................................................... 32 Possible causes and sources of illnesses in the BAe 146 ............................................... 32 Engine oil and oil seals .............................................................................................. 33 Pack burns .................................................................................................................. 35 Difficulty in finding the source of fumes ....................................................................... 36 Issue of toxicity in relation to exposure to fumes........................................................... 36 Toxic Exposure .......................................................................................................... 37 Tricresyl phosphate (TCP) ......................................................................................... 38 Aerotoxic syndrome ................................................................................................... 39 Mobil Jet Oil II and the issue of toxicity........................................................................ 39 Labelling of Cans Containing Mobil Jet Oil II .......................................................... 44 Development of a new Mobil jet oil .......................................................................... 46 The Alysia Chew case .................................................................................................... 47 Medical evidence............................................................................................................ 49 Other clinical symptoms................................................................................................. 50 CHAPTER FOUR ............................................................................................ 53 TESTING BAe 146 CABIN AIR FOR FUMES - AUSTRALIAN INITIATIVES AND RESULTS......................................................... 53 Study of toxic fumes on US aircraft ............................................................................... 53 Study of toxic fumes on BAe 146 aircraft in Australia and conclusions ....................... 55 Criticisms of tests and studies carried out on the BAe 146 in Australia.................... 60 Response to criticisms of current Australian testing methods ................................... 63 New testing program by British Aerospace ............................................................... 64 Australian attempts to resolve the problem of fumes on the BAe 146........................... 64 Actions taken by Ansett ............................................................................................. 65 Comment on Ansett’s actions on the BAe ................................................................. 67 Actions taken by Qantas and National Jet Systems Pty Ltd ...................................... 69 Criticism of airline measures to address the fumes issue........................................... 70 CASA’s support for airline action.................................................................................. 74 CASA’s view on the significance of fumes on-board the aircraft.................................. 75 CASA’s view on the BAe 146........................................................................................ 76 Criticism of CASA’s approach....................................................................................... 77 vi CHAPTER FIVE.............................................................................................. 83 IMPACT OF AIR QUALITY ON AIR SAFETY.......................................................... 83 Introduction ....................................................................................................................83 Safety implications of illnesses ...................................................................................... 83 BAe 146 cabin air quality and air safety ........................................................................ 85 The Frank Kolver incident – BASI Occurrence Brief No 199702276....................... 85 BASI Occurrence Brief.......................................................................................... 86 Criticism of BASI Occurrence Brief...................................................................... 88 Incidents of pilot incapacitation in Australia and overseas........................................ 90 1 29 October 1997 - Hamilton Island incident...................................................... 91 2 1997 - Brisbane incident .................................................................................... 92 3 31 March
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