HOUSE OF LORDS

Science and Technology Committee

1st Report of Session 2007–08

Air Travel and Health: an Update

Report with Evidence

Ordered to be printed 14 November 2007 and published 12 December 2007

Published by the Authority of the House of Lords

London : The Stationery Office Limited £price

HL Paper 7

Science and Technology Committee The Science and Technology Committee is appointed by the House of Lords in each session “to consider science and technology”.

Current Membership The Members of the Science and Technology Committee are: Lord Broers (Chairman) Lord Colwyn Baroness Finlay of Llandaff (co-opted) Lord Haskel Lord Howie of Troon Lord May of Oxford Lord O’Neill of Clackmannan Lord Patel Lord Paul Baroness Perry of Southwark Baroness Platt of Writtle Earl of Selborne Baroness Sharp of Guildford Lord Sutherland of Houndwood Lord Taverne

For declared interests of the Members of the Committee see Appendix 1.

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CONTENTS

Paragraph Page ABSTRACT 6 Chapter 1: Introduction 7 Impact of the original report—overview 1.1 7 Reasons for the present inquiry 1.7 8 Acknowledgements 1.14 9 Chapter 2: Changes in Regulatory Arrangements since 2000 10 The Aviation Health Working Group (AHWG) 2.1 10 Box 1: Remit of the Aviation Health Working Group 10 The Aviation Health Unit (AHU) 2.5 11 The Civil Aviation Act 2006 2.9 11 The European Aviation Safety Agency 2.10 12 Other changes in regulatory arrangements 2.12 12 Chapter 3: Research since 2000 15 The scope of research 3.1 15 Box 2: Summary of prioritised research needs 15 Anthropometric Study to Update Minimum Aircraft Seating Standards 3.3 17 Cabin Air Quality 3.6 17 Study of Air Quality in the Aircraft Cabin 3.9 18 Extent of Aspirin Use for the Prophylaxis of DVT on Long Haul Flights 3.10 18 WRIGHT Project 3.11 18 CabinAir 3.15 19 Health Effects of Aircraft Cabin Environment (HEACE) 3.16 20 Ideal Cabin Environment (ICE) 3.17 20 Friendly Aircraft Cabin Environment (FACE) 3.18 20 Mortality and Cancer Rates 3.19 20 United Kingdom research capacity 3.20 20 Gaps in research 3.23 21 Chapter 4: Areas for Action Raised in the Current Inquiry 24 The Cabin Environment 4.1 24 Deep Vein Thrombosis 4.12 26 Infectious Diseases 4.18 27 Air Crew Occupational Health 4.30 30 Contaminated Air Events 4.38 31 Fitness to Fly 4.53 34 BOX 3: Advice on contraindications to air travel by the WHO 35 Information and Education 4.58 36 Chapter 5: Summary of Recommendations 39 Regulatory arrangements 5.1 39 Research 5.4 39 The cabin environment 5.9 40 Deep vein thrombosis 5.11 40

Infectious diseases 5.12 40 Air crew occupational health 5.14 40 Contaminated air events 5.16 41 Information and education 5.20 41 Appendix 1: Members and Declarations of Interest 42 Appendix 2: Witnesses 43 Appendix 3: Call for Evidence 45 Appendix 4: Seminar 46 Appendix 5: Summaries of Individual Submissions 50 Appendix 6: List of Acronyms and Abbreviations 55

Oral Evidence British Airways Plc, Virgin Atlantic, British Air Transport Association Written Evidence (British Airways Plc) 1 Written Evidence (Virgin Atlantic) 4 Oral Evidence, 26 June 2007 7

Professor Michael Bagshaw, Dr Sarah MacKenzie Ross, Professor Helen Muir, Dr William Toff, WRIGHT Project Scientific Executive Committee Written Evidence (Dr MacKenzie Ross) 25 Written Evidence (WRIGHT Project Scientific Executive Committee) 27 Oral Evidence, 10 July 2007 30

British Airline Pilots Association (BALPA), Air Transport Users Council (AUC), Independent Pilots Association (IPA) Written Evidence (BALPA) 39 Written Evidence (AUC) 40 Written Evidence (IPA) 41 Oral Evidence, 10 July 2007 43 Supplementary Written Evidence (IPA) 52

The Department for Transport, the Department of Health, the Civil Aviation Authority Written Evidence 54 Oral Evidence, 17 July 2007 58 Supplementary Written Evidence (Department for Transport) 74 Further Supplementary Written Evidence (Department for Transport) 97

Written Evidence Aerospace Medical Association 98 Aerotoxic Association 99 Airbus 99 Association of Flight Attendants 103 Aviation Organophosphate Information Site 106 Boeing Company 113 British Airline Pilots Association’s Occupational Health & Safety Group 115 Building Research Establishment 118 Dr Clement E Furlong 119 Global Cabin Air Quality Executive 120 Health Protection Agency 124 Ideal Cabin Environment Project 125 Dr G A Jamal 126 Dr Peter Julu 127 Captain Susan Michaelis 127 NYCO 131 Mr Ian Panton 132 Research Institute for Sport and Exercise Sciences, Liverpool John Moores University 133 Ms Christine Standing 136 Thomsonfly 145 Unite the Union—Transport and General Workers’ Section 147 Unite the Union—Transport and General Workers’ Section—Health & Safety Representative 149

NOTE: References in the text of the report are as follows: (Q) refers to a question in oral evidence (p) refers to a page of written evidence

ABSTRACT

Our report on Air Travel and Health, published in 2000, brought together for the first time the wide spectrum of health issues associated with air travel. The report stimulated research into air crew and passenger health, not only in the United Kingdom but beyond. Our understanding of the major health issues connected with air travel is now much improved—though there are still some crucial gaps in knowledge. In 2001 the Aviation Health Working Group was created as a free-standing interdepartmental group to work with interested parties in taking forward the recommendations in the report. The Group has been generally well received by industry, crew and passenger representatives. The Aviation Health Unit was set up in 2003 within the Civil Aviation Authority to act as a focal point for aviation health in the United Kingdom, while the Civil Aviation Act 2006 gave the Secretary of State the general duty of organising, carrying out and encouraging measures for safeguarding the health of all persons on board an aircraft. These changes are welcome, though in some areas more work is needed to add substance to the organisational outlines. Certain health issues still remain a concern. The United Kingdom has supported the World Health Organization Research into Global Hazards of Travel (WRIGHT) project that studied the risk of venous thromboembolism (VTE) associated with air travel. The study concluded that for individuals without VTE risk factors travelling by air did not increase the risk of VTE any more than when travelling by other means. Phase II of the project will look more in depth at the VTE risk for individuals with existing risk factors and also will study preventative measures. We urge the Government to continue to support the project. Public and media interest in contaminated air events, or fume events, has significantly increased in recent years. The independent Committee on Toxicity of Chemicals in Food Consumer Products and the Environment (COT) has conducted a scientific review of the evidence for claims that fume events have damaged the health of pilots and others, and has concluded that the link between fume events and health effects is still unproven, though worthy of further investigation. We support this general conclusion; although much anecdotal evidence has been submitted to the COT and to this inquiry regarding fume events, this evidence still falls short of conclusive scientific proof. However, we recommend that research to settle this issue one way or another be taken forward as a high priority.

Air Travel and Health: an Update

CHAPTER 1: INTRODUCTION

Impact of the original report—overview 1.1. At the end of the 1990s public concern about the health effects of air travel became increasingly acute. At the same time the evidence for such health effects was still largely anecdotal and heavily influenced by a number of widely reported cases of deep vein thrombosis (DVT)1. The state of scientific knowledge of aviation health issues was inconsistent and there was no strategy underpinning research. In response to this state of affairs we set up an inquiry in November 1999 to look into all aspects of air travel and health. We heard evidence from a wide range of organisations and individuals representing manufacturers, airlines, cabin crew, passengers and Government departments. Our report was published in November 20002. 1.2. The report was well received and, in the words of the British Medical Association (BMA), “is generally agreed to be the most authoritative and detailed study of aviation health issues yet written”3. The impact of our report was not limited to the United Kingdom. Dr Nigel Dowdall, Head of Health Services at British Airways, told us “the original House of Lords report has stimulated a much greater interest in passenger and crew health, and that is seen not just in the Aviation Health Working Group (AHWG) and the Aviation Health Unit (AHU), it is seen in the activity that is taking place in Europe and in the world” (Q 9). 1.3. The Government response to the original report was positive and congratulated the Committee for “bringing together the full range of health issues … an exercise which to the Government’s knowledge has not been previously attempted elsewhere.” They also pledged to “work closely with passenger organisations, medical experts and the industry to ensure that the range of issues the Committee has identified receive the attention they merit”4. 1.4. The response set out ambitious plans for the future, including bringing together professionals and Government departments to oversee aviation health in the form of the AHWG. The Government also endeavoured to stimulate and encourage research in this area which until then had been neglected. Their first step was to commission a study to identify areas of concern and gaps in knowledge with a view to targeting future research. 1.5. More recently, the Government changed the law in 2006 to give the Secretary of State the “general duty of organising, carrying out and encouraging measures for safeguarding the health of persons on board

1 We use the term DVT in this report as it is the initial deep vein thrombosis that may be related to the aircraft cabin environment. Venous thromboembolism (VTE) is a complication which occasionally arises from DVT and this term is used in some of the evidence. 2 Science and Technology Committee, 5th Report (1999–2000): Air Travel and Health (HL 121-I). (Hereafter referred to as Science and Technology Committee Air Travel and Health 2000). 3 See http://www.bma.org.uk/ap.nsf/AttachmentsByTitle/PDFFlying/$FILE/Impactofflying.pdf 4 See http://www.dft.gov.uk/transportforyou/airtravel/safety/airtravelandhealthgovernment6189 8 AIR TRAVEL AND HEALTH: AN UPDATE

aircraft”5, thus addressing a regulatory void in aviation health. The Civil Aviation Act 2006 also amended the functions of the Civil Aviation Authority (CAA) to include responsibility for the health of all persons aboard aircraft, not just crew. 1.6. The impact of our report on commercial airlines was also significant. Most airlines updated the information they gave to passengers on fitness to fly and the risks associated with air travel for those with existing medical conditions. Some airlines also included advice on the prevention of DVT on their inflight magazines and as part of their safety briefing prior to or shortly after take-off. High efficiency particulate air (HEPA) filters, although not yet mandatory, are now fitted as standard on most aircraft and the majority of long-haul airlines carry automated external defibrillators.

Reasons for the present inquiry 1.7. The previous section shows that much has changed, largely for the better, since 2000. Yet public concerns over the health effects of air travel remain high. To this day the Committee regularly receives correspondence on aviation health from individuals, pressure groups and charities. For instance, at the end of 2006 we received a letter from the Work-related Death Advice Service, a charity funded by the Joseph Rowntree Charitable Trust, which provides advice to families bereaved by work-related deaths. The letter claimed that a number of key findings in the Committee’s original report—in particular, that there was no regulatory body willing to take responsibility for protecting passenger health—had still not been addressed. 1.8. There have also been a number of reports in the press of alleged contaminated air events affecting the health of pilots and passengers. Two major health threats, the outbreak of severe acute respiratory syndrome (SARS) in 2002–03 and the increasing threat of an influenza pandemic since 2004, have focused attention on the role of air travel in the spread of disease. 1.9. At the same time the number of people travelling internationally is increasing every year. According to statistics issued by the World Tourism Organization, international tourist arrivals exceeded 800 million in 2005, of which 45 percent had travelled by air6. The advent of ultra long-haul services on wide-body aircraft will enable airlines to carry larger numbers of passengers in flight for longer periods. With the expansion of low-cost airlines domestic air travel within the United Kingdom has also increased dramatically in the last few years. There has also been an upsurge in air travel amongst older people. 1.10. The Committee therefore decided that the time was right to revisit the subject and examine what progress had been made since 2000 in the form of a short follow up inquiry. 1.11. In Chapter 2 of this report we enumerate the changes in regulatory arrangements since 2000. Chapter 3 describes the different research projects that have taken place since the original inquiry and in Chapter 4 we tackle the issues that are still pending and new areas of concern.

5 Section 8, Civil Aviation Act 2006 6 See http://www.unwto.org/media/news/en/press_det.php?id=621 AIR TRAVEL AND HEALTH: AN UPDATE 9

1.12. Our 2000 report was very comprehensive, and in the course of this shorter follow-up we have not been able to cover all issues raised at that time. Where an issue referred to in 2000 is not brought up in this report it is because we have not received any new evidence in that area, not because we do not regard it as important. 1.13. We issued a call for evidence which is reprinted in Appendix 3. We received substantial amounts of written evidence from airlines, manufacturers, unions and pressure groups. Written evidence was supplemented with oral evidence heard at three public meetings held in July. We also received many personal accounts from pilots and others who believe they have suffered ill health following contaminated air events. Such contributions, although we have not treated them formally as evidence, are summarised in Appendix 5 and can be viewed by appointment in the Parliamentary Archives.

Acknowledgements 1.14. The membership of the Committee is set out in Appendix 1. We are grateful to those who submitted written and oral evidence, who are listed in Appendix 2. We launched the follow up inquiry with an informal seminar held on 21 June 2007, a note of the seminar is given in Appendix 4. We are very grateful to all participants in this event 1.15. Our Specialist Adviser for this inquiry was Dr Michael Glanfield, Aviation Medicine Specialist and Engineer. We are grateful to him for his expertise and guidance throughout our inquiry. However, the conclusions of this follow-up inquiry are ours alone. 10 AIR TRAVEL AND HEALTH: AN UPDATE

CHAPTER 2: CHANGES IN REGULATORY ARRANGEMENTS SINCE 2000

The Aviation Health Working Group (AHWG) 2.1. In response to the Committee’s original report the Government set up in 2001 the AHWG, a free-standing interdepartmental group chaired by the Department for Transport (DfT). The remit of the AHWG is given in Box 1. Members of the group include representatives of the Department of Health (DH), the CAA, the Health and Safety Executive (HSE), airlines, unions and passenger groups. The AHWG has recently reviewed how it operates and widened its membership to include representatives of aircraft manufacturers. The Group has met 25 times since it was set up in 2001. BOX 1 Remit of the Aviation Health Working Group The Aviation Health Working Group will meet on a regular basis and will work in partnership with other interested parties to give effect to the Government response to the House of Lords Inquiry into Air Travel and Health. Particular responsibilities identified in the response are to: • Provide a forum for interested Government departments and agencies to consider issues relevant to aviation health; • Provide an interface with the air transport industry, health experts and other interested parties on aviation health issues of mutual interest; • Evaluate the need for research into issues related to air travel and health, and consider the role of Government in supporting such research; • Ensure Ministers are kept informed and receive comprehensive advice on aviation health matters; • Monitor developments that impinge on the health of those travelling by air.

2.2. The AHWG has also set up a research sub-group, chaired by the DH, which considers research proposals and needs. During the first two years the sub- group focused on DVT as well as a range of topics including air quality. 2.3. We heard some criticisms of the speed of work of the AHWG, particularly in the early years. Peter Jackson, a Director of the Independent Pilots’ Association (IPA), which is not represented on the AHWG, felt that progress had been slow. He told us that “bearing in mind your Lordships’ recommendations came out in 2000 and the AHWG has only been effective for the last two years, a lot of time has been wasted” (Q 176). Even strong supporters of the Group such as Captain Tim Bamber, National Executive Committee Member of the British AirLine Pilots Association (BALPA), which is represented, commented on the speed of work: “it might have been slow off the ground, the AHWG did not hit the ground running, but in the last couple of years it has started working extremely well together” (Q 179). 2.4. Notwithstanding these criticisms, in general the AHWG has been well received by the industry, unions, the regulatory authorities and passenger AIR TRAVEL AND HEALTH: AN UPDATE 11

representatives. Dr Nigel Dowdall told us that “it [the AHWG] works very effectively; I guess like most people I was perhaps slightly sceptical of how it would work when it was first set up but I have been very impressed with the work that has happened” (Q 9).

The Aviation Health Unit (AHU) 2.5. The AHU was set up in December 2003 within the CAA to improve understanding and knowledge of aviation health and to act as a “focal point” for these matters in the United Kingdom. The AHU is “the primary source of advice to DfT, DH and industry” (p 74). The head of the AHU is also a member of the AHWG, reporting to the Chief Medical Officer of the CAA. The AHU dealt with “around 100 queries”7 from members of the public in 2005 and they also have input into the responses to queries from passengers received by DfT. 2.6. Simon Evans, Chief Executive of the Air Transport Users’ Council, said of the AHU: “we have taken great comfort from the setting up of the Aviation Health Unit within the Civil Aviation Authority, which does provide a repository for information and for people to know that there is an organisation taking care of concerns about health in aviation that were not being taken account of previously.” (Q 179) 2.7. But even though we were told that the AHU is “actively working to improve the visibility of the AHU for the travelling public” (Q 238), we question how effective it has been, and how much awareness there is among the travelling public of the work, and indeed the existence, of the AHU. We heard from members of the public of the difficulties they encounter when trying to get information on aviation health matters or when trying to make a complaint which is health related. For instance, in one unpublished submission we were told that “the CAA was the biggest fiasco I encountered with telephoning and being passed around to so many departments and no one knowing who should deal with this, I sent several emails regarding passenger health and received two emails back stating that passenger health was not within their remit and was a matter for the airline, as was consumer issues!”. More broadly, the letter from the Work-related Death Advice Service mentioned above stated: “there appears to be no effective enforcement that we can see of health and safety law in relation to passenger health issues”. 2.8. Thomsonfly also told us that their understanding of the AHU was limited, adding “we would suggest that the AHU should consider raising its profile within the industry and should ensure a regular contact program with the UK based airlines to ensure an increased level of self promotion” (p 145).

The Civil Aviation Act 2006 2.9. The developments already described were given a formal legal foundation by means of the Civil Aviation Act 2006. This gave the Secretary of State the general duty of organising, carrying out and encouraging measures for safeguarding the health of persons on board aircraft. The functions of the CAA, as set out in the Civil Aviation Act 1982, were also amended to include the health of persons aboard aircraft. The Act also gave the CAA the powers to recoup from the industry the costs of its AHU, some £200,000 a

7 AHWG Minutes 18 November 2005 12 AIR TRAVEL AND HEALTH: AN UPDATE

year8. In the words of Jim Fitzpatrick MP, Parliamentary Under-Secretary of State for Transport, these changes in the law are “a world first” (Q 226).

The European Aviation Safety Agency 2.10. In 2003 the European Aviation Safety Agency (EASA) was set up to be an independent body under European law. It was designed to succeed the Joint Aviation Authorities (JAA), which represented the civil aviation authorities of 42 member countries, mainly European. The aim of EASA is to co-ordinate safety regulation across Europe and “to promote the highest common standards of safety and environmental protection in civil aviation”9. It has a Management Board with representatives from the EU Member States and the European Commission. 2.11. Since its creation EASA has progressively absorbed responsibilities from EU Member States’ national regulatory bodies. In 2008 EASA is expected to assume responsibility for, among other things, air operations—which may include aviation health. We echo the concerns about this additional transfer of responsibilities expressed in the House of Commons Transport Committee’s report The Work of the Civil Aviation Authority10. This states: “it is clear that this organisation [EASA] is not yet ready to do its job and it is vital that the UK transfers no further responsibilities to it until it has shown itself capable of undertaking its existing responsibilities”. It would be very unfortunate if the good work of the Government and the CAA in aviation health were to vanish with the transfer of responsibilities. Sandra Webber, Chairman of the AHWG, told us that EASA “is looking to take on health responsibilities in the future. They have asked us to go and visit them … to talk about what we would see as the priorities we would want them to pursue” (Q 268). The Head of the AHU and the Chief Medical Officer of the CAA will participate in these discussions. It is essential that the message gets through to EASA.

Other changes in regulatory arrangements 2.12. The regulatory framework for occupational and passenger health has continued to develop in recent years. In 2004 the Civil Aviation (Working Time) Regulations11 were passed, implementing the provisions of Council Directive 2000/79/EC concerning the European Agreement on the Organisation of Working Time of Mobile Workers in Civil Aviation. They state the maximum working hours for aircrew and regulate rest periods and working patterns. These regulations also assign responsibilities to the CAA for regulating occupational health and safety on board aircraft. 2.13. The Control of Noise at Work Regulations 200512 came into force in 2006 to implement the European Directive 2003/10/EC Physical Agents (Noise) Directive. The Directive was designed to protect employees from exposure to noise at work and includes aircrew. The Government also set up the Aviation Occupational Health and Safety Working Group to look at certain aspects of

8 HC Deb 9 April 2003 col 257W 9 See http://www.easa.eu.int/home/aboutus_en.html 10 Transport Committee 13th Report (2005–06): The Work of the Civil Aviation Authority (HC 809) 11 See http://www.opsi.gov.uk/SI/si2004/20040756.htm 12 See http://www.opsi.gov.uk/si/si2005/20051643.htm AIR TRAVEL AND HEALTH: AN UPDATE 13

crew health and safety in the cabin environment. The group is chaired by the CAA with membership drawn from airline unions. 2.14. The CAA continues to review its responsibilities in the field of occupational health. As recently as August 2007 it published Civil Aviation Publication (CAP) 757, a guide on “Occupational Health and Safety on-board an Aircraft”13 aimed at aircraft operators and others involved in the operation of aircraft. We welcome this guide, which covers such areas as manual handling, burns, trips and falls and biohazards. However, we note that CAP 757 does not mention fume events or chemical exposure (issues which are certainly regarded in some quarters as fundamental to occupational health in the air). We return to this issue in Chapter 4. 2.15. At the same time as developing its guidance on occupational health, the CAA has engaged in dialogue with the HSE, with a view to clarifying possible overlaps in the regulatory responsibilities of the two bodies. In 1999 a Memorandum of Understanding (MoU) was drawn up by the HSE and the CAA to provide clarity between the separate disciplines of regulating aircraft safety and the regulation of occupational health and safety. In March 2005 “Annex 8” to the existing MoU was published, with agreed guidelines setting out their respective responsibilities for enforcing occupational health and safety in relation to public transport aircraft while on the ground and in the air14. 2.16. In broad terms the HSE is responsible for regulating the health and safety of “all work activities on and around an aircraft on the ground” including the health and safety of crew members while outside the aircraft. Meanwhile the CAA is responsible for the regulation of health and safety of crew members while they are on board an aircraft. What remains unclear is who has responsibility for the health and safety of passengers on board an aircraft— the issue raised by the Work-related Death Advice Service. The HSE is responsible while the aircraft is “on the ground with the doors open, or the aircraft is manoeuvring or being manoeuvred on the ground without the intention of flight”. It may be inferred that the CAA is responsible for the health and safety of passengers while on board an aircraft but neither the MoU nor Annex 8 says so specifically.

Recommendations 2.17. We welcome the establishment of the AHU within the CAA. However, we recommend that the AHU and the CAA work together with Government departments and the aviation industry in raising the profile of its work so that it becomes the focus for airlines, passengers and health care professionals in their quest for information on aviation health matters. The AHU should become the body responsible for handling queries and complaints from passengers on health issues and should publish guidelines on how those queries will be handled. 2.18. We agree with the House of Commons Transport Committee that the United Kingdom cannot and must not transfer any further responsibilities from the CAA to EASA until it is clear that EASA is

13 See http://www.caa.co.uk/application.aspx?catid=33&pagetype=65&appid=11&mode=detail&id=1842 14 See http://www.caa.co.uk/default.aspx?catid=17&pagetype=68&gid=1046 14 AIR TRAVEL AND HEALTH: AN UPDATE

competent to exercise such responsibilities. We recommend that the Government make the strongest possible representations to the European Commission and EASA that the high priority afforded to aviation health in the United Kingdom as a result of the work of the AHWG, the CAA and the AHU must be replicated within EASA. 2.19. We applaud the Government for having taken the steps necessary to make aviation health a priority. The United Kingdom has always been at the forefront in aviation issues and our regulatory arrangements continue to be seen as a model by other countries. However, we recommend: • that the Memorandum of Understanding between the HSE and the CAA, and in particular its Annex 8, should spell out who has specific responsibilities for the health and safety of passengers; • that the HSE and CAA review the interpretation of “occupational health” as it applies to air crew, to ensure that emerging health issues are adequately reflected in regulatory arrangements. AIR TRAVEL AND HEALTH: AN UPDATE 15

CHAPTER 3: RESEARCH SINCE 2000

The scope of research 3.1. Our original report recommended that the Government commission research into a number of priority matters. In their response the Government announced that they had commissioned the Institute for Environment and Health (IEH) to conduct a consultation exercise to confirm independently the concerns identified by our inquiry and to investigate any other potential issues and gaps in knowledge with a view to promoting or facilitating further research. Stage 1 of the study into Possible Effects on Health of Aircraft Cabin Environments15 was published in January 2001. It identified five main areas where more research was needed: DVT, air quality (physical and chemical aspects), transmission of infection, cosmic radiation and jet lag. 3.2. Stage 2 of this study was published in June 2001 and the AHWG considered the report at its meeting on 27 July of that year16. The Stage 2 report investigated the current stage of knowledge on each of the five issues identified in Stage 1 and pointed out shortfalls. The results are summarised in Box 2. We welcome this clear and helpful statement of the main research priorities, against which subsequent research activity must be considered. Below we summarise the main research projects that have since taken place. BOX 2 Summary of prioritised research needs

High Priority

Deep Vein Thrombosis • Improved case-control studies (with particular attention to the selection of controls). • Prospective studies, based on measurements prior to symptoms becoming apparent. • Interaction of DVT risk with hypoxia and exercise.

Cabin air quality (CAQ) • Investigate the key CAQ parameters in flight: the blood oxygen saturation of crew members and passengers, pressures and rates of change, temperature, air movement, humidity, ventilation rate and concentrations of common pollutants and organophosphates, self-reported health and comfort.

Jet lag • Inclusion of jet lag as a confounding effect in studies of DVT, CAQ and infection risk.

15 See http://www.dft.gov.uk/pgr/aviation/hci/hacc/study/ 16 Minutes of AHWG 27 July 2001 16 AIR TRAVEL AND HEALTH: AN UPDATE

Medium Priority

Deep Vein Thrombosis • Experimental biomedical research, on the possible effects of decreased cabin pressure, low partial pressure of oxygen, stress.

Cabin air quality • As for high priority recommendation, but for occupied aircraft on the ground. • Laboratory/simulation studies of the CAQ parameters, the effects of interactions. • Intervention trials on the impact of altering parameters that correlate with health outcomes (e.g. humidification, gas phase air filters, reduced temperature). • Measurement of exposure to insecticides and organophosphates.

Transmission of infection • The incidence of the infectious agents of TB should be determined in the air, and on furnishings and filters on flights from countries where TB is endemic.

Cosmic radiation • Exposure monitoring of cabin and flight crews. • Further development of biological markers for cancer risk.

Low Priority

Deep Vein Thrombosis • Co-ordinated case studies to clarify estimates of the incidence of recent travel in DVT patients (if possible, in association with case-control studies).

Cabin air quality • A survey of air filter condition and maintenance (this would also be relevant to transmission of infection).

Transmission of infection • The effect on the movement of pathogens of adjustable air supply nozzles. • Cosmic radiation • A large epidemiological study on the magnitude of risk, including discrimination of skin cancers risks from CR and UV exposure.

Jet lag • Desk study of the short-term and long-term health and safety implications of jet lag, and the economic implications. AIR TRAVEL AND HEALTH: AN UPDATE 17

Anthropometric Study to Update Minimum Aircraft Seating Standards 3.3. This study was commissioned by the CAA on behalf of the JAA and published in September 200117. At the time of our original report this study was under way and we recommended that “it be completed urgently”18. The study reviewed the UK CAA Airworthiness Notice 64 (AN64), published in 1989, which regulates the minimum seat space dimensions for all UK- registered aircraft over 5,700 kg which carry 20 passengers or more. The United Kingdom is the only country in the world to have regulations on seat spacing. 3.4. The study also took account of the increase in size of people over time. It stated that AN64 “is based on data for 5th percentile to 95th percentile range of passenger sizes, which means that at least 10 percent of passengers will not be accounted for”. It went on to say that “it is widely recognised that where safety is concerned the range should be increased to cover the 1st percentile to 99th percentile range.” 3.5. The study also stated that, as a result of the continuing increase in the average size of the European population since AN64 was published in 1989 (an increase that may accelerate with the projected rise in obesity described in the recent Foresight report19), it would, by 2001, only have accommodated up to 77th percentile of the population. It recommended that the regulatory minimum distance between seats20 be increased to a minimum of 28.2 inches or ideally to at least 29.4 inches to include the 1st percentile to 99th percentile range of the population. It also found that “the current requirement does not provide enough space for taller passengers to adopt the ‘brace’ position” calling for the ability of passengers to adopt the brace position to be considered as one of the criteria for determining acceptable seat space. We return to the issue of seat spacing in Chapter 4 below.

Cabin Air Quality 3.6. We have already drawn attention to Stage 2 of the study into Possible Effects on Health of Aircraft Cabin Environments of 2001, which identified cabin air quality as a high priority area for research. In 2001, following a small number of reported contaminated air events when flight crew were partially incapacitated, the CAA commissioned a research project into Cabin Air Quality21. The study comprised two phases. Phase 1 was a toxicological review of pyrolysed oil by-products22; this concluded that “no single component or set of components can be identified which at conceivable concentrations would definitely cause the symptoms reported in cabin air quality incidents”. However, short chain organic acids, such as pentanoic and valeric acid, were found. Although these acids can act as irritants, there is no information available on the concentrations needed to cause irritancy. 3.7. Phase 2 of the study was an analysis of contaminated cabin air supply ducts removed from two BAe 146 aircraft. The ducts were found to be

17 See http://www.jaa.nl/research/passenger%20seat%20space.pdf 18 op. cit. Science and Technology Committee Air Travel and Health 2000, paragraph 3.51. 19 See http://www.foresight.gov.uk/Obesity/Obesity.html. 20 The distance between the seat back cushion to the back of the seat in front 21 See http://www.caa.co.uk/docs/33/capap2004_04.pdf 22 Oil heated to very high temperatures similar to those in an aircraft engine. 18 AIR TRAVEL AND HEALTH: AN UPDATE

“contaminated with carbonaceous material containing chemicals entirely consistent with the pyrolysis products of aircraft engine oil.” Again, short chain organic acids were also found together with some additional compounds such as the ortho isomer of tricresyl phosphate (TOCP). However, “toxicological review of these previously unrecorded chemicals [TOCP] indicates that they are most unlikely to be present in sufficient concentration to have a physiological effect and, in any case, the specified symptoms were not the same as those associated with exposure to TOCP”. 3.8. As a result of this study, published in 2004, the CAA required operators and manufacturers of particular aircraft types to make a number of changes to minimise oil leaks into the bleed air. According to the report, service records show that “these actions have controlled any airworthiness risk by reducing both the number and severity of reported events”. We return to the issue of “contaminated air” in Chapter 4 below.

Study of Air Quality in the Aircraft Cabin 3.9. The Study of Air Quality in the Aircraft Cabin23 was published in October 2003. It was commissioned by the AHWG and conducted by the Building Research Establishment (BRE) as an extension of the CabinAir project (detailed below), to include measurements on older aircraft types, the BAe 146 and the Boeing 737–300. Fourteen flights were monitored measuring air quality parameters with the aim of determining whether the cabin air quality in these older aircraft was in any way an issue, and whether they differed significantly from newer types of aircraft. The study found that all measured air pollutants on board the flights were always below recommended health limits, when these applied. Comparisons with the CabinAir study have not taken place yet but early results suggest that there are no obvious differences in the cabin environment between older and new aircraft.

Extent of Aspirin Use for the Prophylaxis of DVT on Long Haul Flights 3.10. In 2004 Synovate Healthcare were commissioned by the AHWG to carry out a study aimed at quantifying the extent of aspirin usage amongst UK long- haul aircraft passengers, in order to assist discussions in the AHWG and to facilitate the development of public health policy regarding DVT. A total of 1,672 face-to-face interviews were conducted between 8 September and 29 November 2004. These showed that of the total sample analysed, 20 percent had taken or planned to take aspirin before, during or after their long haul flight24. We return to this issue in paragraphs 4.15–4.17 below.

WRIGHT Project 3.11. At the time of our original inquiry DVT was the one health issue above all others that seemed to concern the flying public. It was also identified as a priority research area in Stage 2 of the Possible Effects on Health of Aircraft Cabin Environments. The AHWG decided soon after its creation, at the end of 2001, that supporting and funding the World Health Organization (WHO) Research Into Global Hazards of Travel (WRIGHT) project, would

23 See http://www.dft.gov.uk/pgr/aviation/hci/hacc/bre/finalreport 24 See http://www.dft.gov.uk/pgr/inclusion/dvt/asprin/theextentofaspirinuseforthep3258 AIR TRAVEL AND HEALTH: AN UPDATE 19

be the best way to fill the research gap on DVT25. Dr Bill Maton-Howarth of the DH said at the AHWG meeting on 11 January 2001 that “the WHO study remained the best match for the objectives of the UK AHWG”26. 3.12. The aim of the WRIGHT project was “to confirm that the risk of venous thromboembolism (VTE) is increased by air travel and to determine the magnitude of risk, the effect of other factors on the risk and to study the effect of preventive measures on risk”27. In the event, the study on preventive measures was deferred to Phase II. 3.13. The project consisted of three epidemiological studies and two physiological studies. Some 1,800 patients referred to six anticoagulation clinics following a first VTE were evaluated in the Netherlands; a study was carried out among frequent flyers employed at major international companies; and questionnaires were sent to all members of the Dutch Airline Pilots Association. The physiological studies included a study on the effects of a hypobaric (low pressure) chamber on 73 healthy volunteers with no risk factors. A further study assessed 71 healthy volunteers with risk factors before, during and after an eight-hour commercial flight. 3.14. The final report of Phase I was published on 28 June 2007. The main findings were: • Travelling for more than four hours in any form of transport approximately doubled the risk of VTE; • The absolute risk of VTE for a flight of more than four hours was 1 in 6,000 passengers, rising to about 1 in 1,000 passengers for longer journeys and multiple flights; • The longer the flight, including multiple trips, the greater the risk of developing VTE; • There was no difference in the relative risk of VTE if the cabin pressure was reduced; • Those who were very short, very tall or overweight were at slightly greater risk; • Travelling by air accentuated other pre-existing VTE risk factors, for example use of oral contraceptives and the presence of prothrombotic blood abnormalities; and • “Hyper-responders” seemed to react to unspecified flight-related factors: if an individual had a risk factor the likelihood of him developing VTE increased dramatically after an eight hour flight.

CabinAir 3.15. This EU-led project is being carried out by the Building Research Establishment (BRE). CabinAir “is one of the largest and most important

25 We remind readers that we use the term DVT in this report as it is the initial deep vein thrombosis that may be related to the aircraft cabin environment. Venous thromboembolism (VTE) is a complication which occasionally arises from DVT and this term is used both in the WRIGHT project and in some of our evidence. 26 AHWG Minutes 11 January 2002 27 See http://www.who.int/cardiovascular_diseases/wright_project/phase1_report/WRIGHT%20REPORT.pdf 20 AIR TRAVEL AND HEALTH: AN UPDATE

studies to be carried out on the environment in aircraft cabins”28. It has looked into health and comfort issues involved in cabin air quality in commercial aircraft. The results of the study are likely to be published within the next few months.

Health Effects of Aircraft Cabin Environment (HEACE) 3.16. This study is EU-led, with BRE as the United Kingdom partner. It aims to understand the impact of the aircraft environment on health and comfort of flight and cabin crew and comprises ground testing in cabin simulators and in-flight monitoring. Although HEACE was scheduled to run for three years, from November 2001 to October 2004, it was prolonged until April 2005. The report has not yet been published.

Ideal Cabin Environment (ICE) 3.17. The Ideal Cabin Environment (ICE) project is an EU-led study aiming to address concerns about the combined effects of cabin environmental parameters on the health and well-being of passengers in commercial aircraft. Dr Ray Johnston, head of the AHU, is the Medical Chair of the Project; he told us that the study “is unique in its approach, looking at health and well- being” (Q 270). Some 1,500 people took part, 50 percent male and 50 percent female, encompassing three age groups (18–34, 35–50 and 50 years plus), and some individuals with cardiac and respiratory diseases. Environmental conditions were examined, including a range of cabin altitudes, as well as psychological well-being. The ultimate aim of the project is “to set a new European standard once the data are analysed” (Q 270). The study will report in the autumn of 2008.

Friendly Aircraft Cabin Environment (FACE) 3.18. The aim of FACE is to improve cabin and cockpit comfort in the next generation of civil transport aircraft. FACE will address the environmental comfort parameters that depend on noise, vibration and air quality technology. The project is EU-led with a budget of approximately 35 million Euros and has 30 European partners. The results have not yet been published.

Mortality and Cancer Rates 3.19. The CAA together with the London School of Hygiene and Tropical Medicine are undertaking a study comparing mortality and cancer rates of pilots, air transport control officers and the general population. The project began in 1997 and preliminary results are being compiled for publication.

United Kingdom research capacity 3.20. It is clear that our original report stimulated considerable research into aviation health. Many, though not all, of the priority areas, have been or are being addressed. However, the projects we have described are all international, and we remain concerned at the amount and quality of research being undertaken in the United Kingdom.

28 See http://projects.bre.co.uk/EnvDiv/cabinair/ AIR TRAVEL AND HEALTH: AN UPDATE 21

3.21. Professor Michael Bagshaw, Aviation Medicine Director at King’s College London, told us that “there is insufficient research” into aviation health in the United Kingdom. He added that “the only substantive research we have had has been from the WRIGHT study from the WHO and the research that has been done on cabin air quality … is pan-European, as opposed to UK- led” and in practice very little of the research is being done in the United Kingdom. He went on to say “there is very little input from Her Majesty’s Government into research in the United Kingdom and I believe that this is a pity”. Although, as far as we are aware, Professor Bagshaw is the only academic in this country at professorial level wholly specialising in aviation medicine, he commented that he was unable himself to conduct any research: “My university does not fund research in civil aviation medicine and there is no source of funding.” (Q 113) 3.22. More generally, we note that many of the international research projects described above, some of which were set up as much as ten years ago, have yet to report. In some cases these are long-term studies, so delays in publication are to a degree excusable. In other cases, however, the complications inherent in pulling together research teams across international boundaries may also have played a part in creating delays. This is frustrating—there can be little doubt that a more intense, UK-based research effort, with Research Council support, would have produced results more quickly as well as building up expertise across the country.

Gaps in research 3.23. There remain gaps in research. In 2000 we recommended an “exploration of the ways different aspects of the aircraft cabin environment may interact, particularly on those in less than average health”29. This recommendation is even more relevant today. Phase I of the WRIGHT Project found that “the more pronounced risk increase observed after air travel compared to ground travel for some of these risk factors may suggest an effect of flight-related factors, which are absent during travel by other modes of transport”30. We expect that the ICE Project may address some of the issues, but it is imperative that we find what these “flight-related factors” are and what effects they have on passengers and in particular on those with existing medical conditions. For instance, the Anthropometric Study to Update Minimum Aircraft Seating Standards recommended that “studies investigate any specific relationships between seating parameters and thromboembolic disease”31. No such studies have taken place. It is essential that the WRIGHT Project addresses this issue. 3.24. We also recommended in 2000 that researchers should be enabled to extract “maximum value from available and improved medical records of aircrew concerning any long-term effects from exposure to the aircraft cabin environment”32. The CAA’s study into mortality and cancer rates is a good start and we will follow with interest the publication of the preliminary results. However, we heard at our seminar of the difficulties that the CAA encountered in carrying out this study. Section 23 of the Civil Aviation Act

29 op. cit. Science and Technology Committee Air Travel and Health 2000, paragraph 9.3. 30 See http://www.who.int/cardiovascular_diseases/wright_project/phase1_report/WRIGHT%20REPORT.pdf 31 See http://www.jaa.nl/research/passenger%20seat%20space.pdf 32 op. cit. Science and Technology Committee Air Travel and Health 2000, paragraph 9.3. 22 AIR TRAVEL AND HEALTH: AN UPDATE

1982 restricts the CAA on how they can use information from pilots’ medical examinations for research purposes. When we put this issue to Jim Fitzpatrick MP he told us that the Government “have not made judgment on it yet” but that it is “something that we are prepared to consider in due course”. 3.25. Stage 2 of the Study of possible effects on health of aircraft cabin environments highlighted jet lag as a high priority area in need of research, and in particular the inclusion of jet lag as a confounding effect in the study of DVT, cabin air quality and infection risk. Also highlighted was the need to study the long- term effects of jet lag—the physiological condition resulting from alterations to the circadian rhythm (the body’s internal clock) due to transmeridian travel—and shift working patterns on air crew. Such issues are increasingly relevant today given the expansion of long haul flights. But to our knowledge little has been done in this area. 3.26. At its meeting on 6 October 2006 the AHWG decided not to support a research proposal from Dr Jane Zuckerman from the Royal Free Hospital to carry out research into the transmission of respiratory infections by or in air travel. However the Group agreed that “there were potential issues, which good quality research could tease out”33. It is interesting to note how the travelling public have come to accept that at times they may contract a cold after a flight and this is assumed to be a “side effect” of air travel. Written evidence submitted to the original inquiry included personal accounts from passengers complaining of contracting respiratory infections following a flight. We concluded in 2000 that the re-circulation of air in aircraft does not in fact aid infection transmission. However, given the public’s perception on this issue it is worth investigating specifically whether any aspect of the flying experience, such as jet lag or psychological factors, makes us more susceptible to contracting respiratory diseases.

Recommendations 3.27. We recommend that the Government fully support Phase II of the WRIGHT Project including investigations on flight-related factors which may increase the risk of VTE, the relationship between seating and VTE, and effective preventive measures. 3.28. We recommend that the Government bring forward an amendment to Section 23 of the Civil Aviation Act 1982 which regulates the use of information from air crew medical records, so that anonymised data can be extracted and used to carry out epidemiological research projects. 3.29. We recommend that jet lag should be studied as a confounding effect of DVT as part of Phase II of the WRIGHT Project. Other research projects, such as FACE should include jet lag in their studies. We also recommend that the CAA, as the body responsible for the health and safety of air crew while on board an aircraft, commission a study into the possible long-term health effects that jet lag may have on air crew. 3.30. We recommend that in addition to contributing to international research projects, the Government and the Research Councils explore ways to increase the research capacity in aviation health that

33 AHWG Minutes 6 October 2006. AIR TRAVEL AND HEALTH: AN UPDATE 23

exists within the United Kingdom. A strong research base in this country is essential if awareness and understanding of aviation health are to be increased across the wider medical profession. 3.31. We find surprising and frustrating the number of EU-led research projects that have not published their reports. We recommend the Government should take an interest in these projects and if possible expedite the publication of their results. 24 AIR TRAVEL AND HEALTH: AN UPDATE

CHAPTER 4: AREAS FOR ACTION RAISED IN THE CURRENT INQUIRY

The Cabin Environment 4.1. We mentioned above the CAA-funded research Anthropometric Study to Update Minimum Aircraft Seating Standards published in 2001. The study recommended that the regulatory minimum distance between seats should be increased to a minimum of 28.2 inches. The report goes on to say that “the ideal recommendation would be to increase … [the regulatory minimum distance between seats] to at least 29.4 inches” to include the 1st to 99th percentile range of the world population; “and, depending on the outcome of any further work to specify an optimum safe brace position, … [the regulatory minimum distance between seats] would need to increase to at least 35 inches”34 . We find it astonishing that the CAA has chosen to ignore this piece of research and its recommendations. Dr Ray Johnston told us, that “no airline … operates a 26 inch pitch”, which is the minimum regulatory standard, and that “every airline that I have researched has a seat pitch greater or equal to 28 inches” (Q 262). This misses the point, which is that the value of a regulatory minimum lies in large part in the signal that it sends to industry of the kind of standards expected for air travel. Moreover, if no airline has a seat pitch of less than 28 inches there would appear to be no reason why the CAA should not implement the recommendations of its own research, and increase the regulatory minimum to 28.2 inches at minimal cost to the industry. The impending transfer of responsibilities to EASA makes this change all the more important. 4.2. In our 2000 report we welcomed the prospect of new products, such as “premium economy” seating, which allow passengers to purchase extra leg room in a long-haul flight for a “modest premium” (Q 3)35. These “premium economy” or “economy plus” services have been designed for those passengers that require space above a reasonable minimum. However, we heard from Roger Wiltshire, Secretary General of the British Air Transport Association (BATA), that this category of products attracts “the high rate of air passenger duty”, along with business and first class. This duty was doubled in February 2007 from £40 to £80 (QQ 3–4). Given that premium economy seating appears to be one way in which airlines are catering for the health requirements of taller passengers, we agree with BATA that premium economy should be taxed at the standard rate of air passenger duty. 4.3. In the original report we recommended that airlines should review and modify their cabin design considerations to include personal air outlets (PAOs). We are pleased to hear that PAOs are standard equipment on some aircraft, including the new Boeing 787 (p 114) due to come into service in the next few months. However, in other models PAOs are considered optional extras. We reiterate our conclusion in 2000, that PAOs can provide personal refreshment to passengers, thus enhancing the flying experience. 4.4. With regards to ventilation, we are gratified to hear that “HEPA filtration for recirculated cabin air is standard equipment on all Boeing production aircraft” (p 114) and all Airbus production aircraft (p 101). For older planes

34 See http://www.jaa.nl/research/passenger%20seat%20space.pdf 35 op. cit. Science and Technology Committee Air Travel and Health 2000, paragraphs 6.33–6.50. AIR TRAVEL AND HEALTH: AN UPDATE 25

there are retrofit solutions. Airbus also told us that “monitoring systems are already in place on the A330 and A340 family or aircraft” which monitor the performance of filters (p 102). 4.5. We also received evidence on cabin pressure. The maximum permitted altitude within the pressurised aircraft cabin is equivalent to 8,000 feet, and at that altitude, even though the percentage of oxygen in the cabin air remains unchanged at 21 percent, the reduction in pressure means that the oxygen level is equivalent to 15 percent at sea level, which is perfectly adequate for healthy individuals. Dr Dowdall told us that “very few aircraft” actually reach the maximum permitted cabin altitude; however, there is no doubt that changes in pressure and in the availability of oxygen take place (Q 98). 4.6. There does not appear to be any firm evidence that these changes in altitude have a significant impact upon normal, healthy individuals. Dr Dowdall argued that the “human body is perfectly able to function” (Q 98) on 15 percent oxygen, and the Aerospace Medical Association (AsMA), which has conducted research in this area, confirmed that they “could find no evidence that lowering the cabin altitude would prevent significant adverse health effects on reasonably healthy passengers and cabin crew.” However, AsMA concluded by saying that it would “encourage more research to be done into this area” (p 98). 4.7. At the same time Dr Dowdall accepted that passengers with pre-existing conditions, such as lung disease, might be more vulnerable to in-flight hypoxia, and for such passengers the provision of supplementary oxygen might be required. The ICE project examined a number of environmental conditions including a range of cabin altitudes from ground level to 4,000, 6,000 and 8,000 feet. The population studied included a subset of individuals with cardiac and respiratory disease. We look forward to the publication of this study in the autumn of 2008. In the long term changes in aircraft construction, such as the use of composites already seen in the Boeing 787, could lead to aircraft being pressurised to a lower level. However, in the meantime, given the dearth of information on the effects of cabin pressure on passengers with existing medical conditions, we agree with AsMA that more research is needed. This research should focus on those with pre-existing conditions that make them vulnerable to hypoxia. 4.8. We mentioned in Chapter 2 the Control of Noise at Work Regulations 2005. We welcome these regulations that remove the exemption that existed in relation to aircraft. On the other hand, while we understand that noise in the aircraft generally has been and is being researched as part of ICE, FACE and HEACE, we have not heard of any research being conducted on noise in the cockpit. The issue remains relevant. We heard from BALPA that “noise induced hearing loss is both permanent and prevalent in the industry yet protection is easily affordable”. British Airways has conducted investigations in the issue and in fact introduced noise-attenuating headsets as a result (p 89). The Government assured us that the Aviation Occupational Health and Safety Working Group, chaired by the CAA, was looking into this issue (p 89).

Recommendations 4.9. We recommend that the CAA implement the recommendations of its own research into aircraft seating standards, and increase the 26 AIR TRAVEL AND HEALTH: AN UPDATE

regulatory minimum distance between seats to at least 28.2 inches. The Government should also make the strongest possible representations to EASA on this subject when they take over responsibility on this issue. 4.10. We recommend that the Government urgently review the level of air passenger duty levied on “premium economy” seating. We further recommend that they explore ways in which the airlines can be encouraged to offer extra space to passengers for a modest premium. 4.11. We welcome the fact that the Aviation Occupational Health and Safety Working Group, chaired by the CAA, is looking into noise- induced hearing loss. However, pending the outcome of this work, we recommend that the CAA work with airlines to review the availability of personal protection equipment so that pilots will be better able to protect their hearing.

Deep Vein Thrombosis 4.12. DVT is a condition in which a small blood clot forms in the deep veins of the legs. Symptoms of this condition include swelling of the leg possibly accompanied by pain and tenderness. In itself DVT is not dangerous but when a blood clot, or thrombus, breaks away from the walls of the vein, blood flow carries it away and it may block a distant blood vessel causing a venous thromboembolism (VTE). A pulmonary embolism occurs when a blood vessel in the lungs is blocked, which can cause breathing difficulties and chest pains, and in extreme cases respiratory failure and death. 4.13. At the time of our original inquiry air travel-related DVT was in the headlines. However, little was known as to the real link between air travel and DVT. The WRIGHT Project has filled some of the gaps in reaching some important conclusions as detailed above. It provides reassurance that for individuals without risk factors for thrombosis the increased risk of DVT when flying is no higher than that when travelling by other means, for example train or bus. However there is still much that is not known, including what cabin environmental factors compound DVT probability in passengers with existing risk factors. We reiterate that the Government should support Phase II of the WRIGHT project to address these issues. 4.14. Public awareness of travel-related DVT has continued to increase since our original report. Media reports have had an influence but also information provided by airlines has improved since 2000. We are concerned, however, at the lack of information targeted not just at the general public, but at those passengers with existing medical conditions, who are thus more susceptible to DVT according to the WRIGHT study. We address this issue in more detail below under the heading “Information and Education”. 4.15. The report on the Extent of Aspirin Use for the Prophylaxis of DVT on Long Haul Flights also revealed some worrying statistics, including reports that 20 percent of passengers of long-haul aircraft passengers questioned had taken or planned to take aspirin before, during or after their long-haul flight. Although this was a small study, we are concerned at the number of people who were thinking of taking aspirin before, during or after a long haul flight. Passenger information on the benefits of taking aspirin for the prophylaxis of DVT seems contradictory. Websites such as flighthealth.org promote the use of aspirin before a flight stating “the day before the flight, take a low does of AIR TRAVEL AND HEALTH: AN UPDATE 27

aspirin (100–150 mg), during the flight, and for three days following the flight”36. On the other hand, the National Travel Health Network and Centre (NaTHNaC) advises passengers on their website “aspirin should not be used for the prevention of DVT in travellers”37. We also heard from Roger Wiltshire that the information that airlines provide to passengers “is being reviewed” to “ensure that we are not encouraging people to take aspirin” (Q 11). 4.16. Dr William Toff, Professor of Cardiology at the University of Leicester and member of the WRIGHT Project Scientific Executive Committee, told us that “for the average traveller the use of aspirin is a relatively ineffective intervention” in the prevention of DVT (Q 128). While it may have an effect in reducing the risk of arterial thrombosis it has no effect on venous thrombosis. Indeed in some cases the use of aspirin may be counter- productive. Dr Toff went on to say that “you have to treat a lot of people to prevent one thrombosis and the estimate would be something in the region of treating 24,000 people to prevent one thrombosis. On the other hand, the number that you need to treat for harm from aspirin is in the region of one in 17,000” (Q 128). In other words, on the balance of probabilities, and for the population as a whole, taking aspirin as prophylaxis is more likely to do harm than good.

Recommendation 4.17. We recommend that the Government and the AHU work together with airlines and others in providing consistent travel advice to passengers on the risks associated with self-medicating with the intention of preventing DVT.

Infectious Diseases 4.18. The general perception that infectious diseases can be transmitted via the cabin air environment has not gone away despite reassurances given by our original report and others such as the WHO. The risk of cross-infection in the aircraft cabin environment is the same as any enclosed space such as an office building. Passengers are at equal or greater risk of transmission of infection in other travel-related situations, such as public transport or airport lounges. 4.19. Although currently HEPA filters are not mandatory the majority of modern commercial aircraft are fitted with HEPA filters. We heard from Mr Wiltshire that “filtration systems now are all up to the highest HEPA filter standards” (Q 5). In our original inquiry we reported concerns about the lack of regulation with regards to maintenance of these filters. We raised this issue at our seminar and we were told that the CAA had responsibility for checking that the filters were maintained regularly as part of the general maintenance schedule and that regular spot checks were carried out. 4.20. However, if the spread of infection on board a flight is not a serious concern, the role of air travel more broadly as a vector in the spread of disease is becoming increasingly clear. Some 40 new pathogens have been discovered since 1967, which, along with familiar pathogens such as influenza and

36 See http://www.flighthealth.org/preventing-dvt.htm 37 See http://www.nathnac.org/travel/factsheets/dvt.htm 28 AIR TRAVEL AND HEALTH: AN UPDATE

tuberculosis, pose a threat to global public health security. One of these new pathogens, SARS, was first identified in southern China in November 2002 and the WHO recognised it as a global threat in March 2003. It has been described as the “first severe and readily transmissible new disease to emerge in the twenty-first century”38. Within a short time SARS affected approximately 8,000 people in 29 countries constituting a major international public health emergency. Despite the clear role of international travel in the spread of SARS during the 2003 outbreak, only one case of in- flight transmission has been confirmed. 4.21. Pandemic influenza potentially poses a much greater threat than SARS. Such pandemics occur on average around three times a century, when a strain of avian influenza acquires the ability to infect and pass efficiently between humans39. Since 1997, when the H5N1 strain of the influenza virus was isolated in humans, it has caused at least 308 deaths. All the victims appear to have contracted the disease through close contact with infected animals, and there have been no confirmed cases of human-to-human transmission. However, should the virus mutate so as to acquire the ability to pass readily between humans, the consequences could be grave. The H1N1 pandemic of 1918–19 is estimated to have killed between 20 and 50 million people. 4.22. Airlines carry two billion passengers each year, potentially enabling disease to travel from one country to another in a matter of hours. This raises the question of what measures could be introduced to slow the spread of disease. One approach would be to seek to isolate the source of an outbreak by stopping all travel in or out of the affected region. This might only delay the spread of a pandemic by a few weeks, but the time gained might be crucial in allowing for the development of a vaccine. At the same time the cost to the global economy of a suspension of air travel to, say, south-east Asia, would be enormous. 4.23. An alternative approach, introduced at the time of the SARS epidemic, is airport screening to “filter out” infected passengers. However, when we asked Professor Bagshaw his opinion on screening procedures at airports he said that that they were not robust enough. He added, “putting a thermometer in somebody’s ear is not very helpful” in detecting individuals in the early stages of influenza (Q 163). This bears out our conclusion in our recent report on Pandemic Influenza that airport screening procedures were unlikely to be effective in preventing a global influenza pandemic. 4.24. We received very little evidence of the extent and level of contingency planning for a possible pandemic, as it affects the airline industry. The airlines reassured us that they had contingency plans in preparedness for a pandemic and that these plans were regularly tested (QQ 60–61). They told us that international organisations such as the WHO, the International Civil Aviation Organisation (ICAO) and the International Air Transport Association (IATA) “have developed protocols and guidance for airlines and for airports” (Q 60). Airlines also work with the DfT, the DH and the AHU in pandemic planning. However, in the absence of details of such plans we are unable to reach any conclusion as to their likely effectiveness. We

38 See http://www.who.int/csr/sars/en/WHOconsensus.pdf 39 For a detailed account see Science and Technology Committee, 4th Report (2005 06): Pandemic Influenza (HL 88) AIR TRAVEL AND HEALTH: AN UPDATE 29

therefore confine ourselves to two basic recommendations to the airlines and the Government detailed at the end of this section. 4.25. The risk of disease transmission within the aircraft cabin environment is greater when sitting within two rows of an infectious passenger for a flight of more than eight hours (Q 57). Indeed, evidence suggests that disease is more likely to be spread by skin contact (whether direct or indirect, via contaminated surfaces in toilet facilities or elsewhere) than via ventilation systems—though advice from WHO shows that viruses such as that which causes SARS lose infectivity after exposure to commonly used disinfectants40. However, transmission becomes widespread within all sections of the aircraft cabin when the ventilation system is non-operational. Indeed the WHO recommend in their Tuberculosis and Air Travel Guidelines that “in case of ground delays of more than 30 minutes, adequate cabin ventilation must be ensured”41. 4.26. We also note that on 15 June 2007 the International Health Regulations (IHR) 2005 came into force globally. These Regulations aim “to prevent, protect against, control and provide a public health response to, the international spread of disease42”. The Government are currently consulting on changes that might be made to the Public Health (Control of Disease) Act 1984 in the light of the IHR 2005. The Regulations highlight seven areas of work: • Fostering global partnerships; • Strengthen national disease surveillance, prevention, control and response systems; • Strengthen public health security in travel and transport; • Strengthen WHO global alert and response systems; • Strengthen the management of specific risks, such as influenza, SARS and yellow fever; • Sustain rights, obligations and procedures; and • Conduct studies and monitor progress on the implementation of the IHR 2005 at national and international level. 4.27. The WHO in their World Health Report 200743 recommend among other things that all countries implement fully the IHR 2005. We agree: the Government must take forward their consultation as a matter of urgency.

Recommendations 4.28. We recommend that the Government and the airlines advise passengers on the proven benefits of good hand hygiene in the reduction of disease transmission and in particular that passenger clean their hands before eating on board an aircraft. In the event of a disease outbreak that could lead to a pandemic, we recommend that as part of their contingency plans airlines flying from affected regions

40 See http://www.who.int/csr/sars/travel/airtravel/en/print.html 41 See http://www.who.int/tb/publications/2006/who_htm_tb_2006_363.pdf 42 See http://www.who.int/mediacentre/news/releases/2005/pr_wha03/en/index.html 43 See http://www.who.int/whr/2007/en/index.html 30 AIR TRAVEL AND HEALTH: AN UPDATE

should provide bactericidal wipes and alcohol gels to limit the spread of disease in-flight. 4.29. We recommend that the Government and the regulators limit the amount of time that passengers can remain in an aircraft when the ventilation systems are non-operational to 30 minutes.

Air Crew Occupational Health 4.30. The current version of CAP 371 was published by the CAA in January 200444. These regulations “set a work pattern for flight crew and cabin crew designed to prevent the onset of fatigue, and yet allow an operator to pursue legitimate business interests”. The spirit of CAP 371 is clear: “The prime objective of a flight time limitations scheme is to ensure that crew members are adequately rested at the beginning of each flying duty period, and whilst flying be sufficiently free from fatigue so that they can operate to a satisfactory level of efficiency and safety in all normal and abnormal situations. Aircraft operators are expected to appreciate the relationship between the frequency and pattern of scheduled flying duty periods and rest periods and time off, and give due consideration to the cumulative effects of working long hours interspersed with minimum rest.” 4.31. However, both the pilots’ unions, BALPA and the IPA, highlighted fatigue as a new health concern which had emerged since 2000. The problem as described by them was that new technology allows airlines to set work schedules far more efficiently, so that pilots are regularly made to work to the maximum flying time permitted by CAP 371—observing the letter of the regulations, but not the spirit. 4.32. More specifically, BALPA’s Occupational Health and Safety Group told us in their written evidence that “fatigue is cumulative, but our rostering systems assume that the tiredness counter in each pilot is reset to zero on the first day of each month and take no account of the previous month’s experiences. This is a potential flight safety hazard which needs a fresh approach” (p 118). 4.33. Other issues were enumerated as compounding the problems, such as very early flights on the first day of a working period and late flights back on the last day of a working period, thus eroding pilots’ rest periods; returning to a different airport than the pilots’ base; the provision by some airlines of self- drive cars for pilots who arrive at a different airport from their normal base; and staff car parking being located far away from base. All these eat into rest time. 4.34. CAP 371 goes on to say “an operator must submit for approval to the CAA a proposed scheme for the regulation of flight and duty times and provision of minimum rest periods”. It follows that the CAA must approve the rostering patterns of all airlines registered in the United Kingdom. At the same time it is worth noting that there are airlines not registered in the United Kingdom that employ British pilots and have bases in airports in the United Kingdom. Such airlines are not bound by CAA regulations.

44 See http://www.caa.co.uk/docs/33/CAP371.PDF AIR TRAVEL AND HEALTH: AN UPDATE 31

4.35. With the expansion of low cost airlines the air travel business has become increasingly competitive. Airlines will naturally seek to maximise productivity from their aircrew. However, this must not be at the expense of safety. When Captain Tim Bamber of BALPA was asked “would you be as clear as saying you have reason to believe some airlines are putting passengers and/or crew at risk by their practices?”, he replied “without hesitation I would say that; yes” (Q 191). 4.36. Jim Fitzpatrick MP told us “the Department for Transport and the CAA are keen to discuss this issue with BALPA. The Secretary of State wrote to BALPA on 5 June 2007 inviting them to come in to discuss their survey with officials, so this is a report that we are indeed taking seriously” (Q 305). He continued, “If safety were to be compromised as a result of fatigue, obviously we would need to address that seriously … The Aviation Health Working Group will be prepared to look at it but that will be a matter pending the outcome of the discussions we will have with them shortly” (Q 307). We will follow with interest the outcome of these conversations.

Recommendations 4.37. We are reluctant to recommend the modification of CAP 371 until more evidence is presented. We recommend, however, that the Government together with the CAA (including the AHU), the unions and airlines work together to find a way of ensuring that pilots have appropriate rest periods and to monitor fatigue complaints by pilots. We also recommend that the CAA, as the body responsible for the health and safety of air crew while on board an aircraft, commission a study into the long-term effects of fatigue in air crew.

Contaminated Air Events 4.38. Most aircraft currently in service or in production have ventilation systems that re-circulate cabin air. In aircraft with re-circulated air systems air from the first stage of the engines (bleed air) is cooled and conditioned (but not filtered) in the air conditioning packs in order to achieve an air pressure and temperature closer to that experienced on the earth’s surface. This air is then mixed with cabin re-circulated air (filtered) in a mixing manifold before being blown to the cabin where the air will circulate for two to four minutes before being expelled from the aircraft. In most cases air supplied to the cockpit is extracted from only one of the two air conditioning packs. 4.39. A contaminated air event (or fume event) takes place when, due to an oil seal failure, engine oil or hydraulic fluid enters the cabin via bleed air from the engines. These oils or fluids are subject to extreme temperatures in the engines which can cause thermal decomposition (pyrolysis) into a range of substances such as volatile organic compounds (VOCs), low molecular weight organic acids, esters, ketones and tri-cresyl phosphate isomers. 4.40. In our 2000 report we concluded that, on the evidence received, the concerns about significant risk to the health of airline passengers and crew arising from contaminated air were not substantiated45. However, public and media interest of such reported incidents has significantly increased in recent years, supported by the emergence of a strong and co-ordinated campaign by

45 op. cit. Science and Technology Committee Air Travel and Health 2000, paragraph 4.41. 32 AIR TRAVEL AND HEALTH: AN UPDATE

a range of organisations dedicated to raising the profile of this issue. Some 80 percent of the submissions received in the course of this inquiry mention contaminated air events as a health concern. Submissions also included personal accounts from pilots who claimed they had suffered ill health, and consequently the loss of their licence, following one or more contaminated air events. 4.41. At the meeting of the AHWG on 27 October 2004 BALPA raised concerns about contaminated air events and the long term health of flight crew and cabin crew. The union requested among other things, an independent study to understand the scale of the problem and a medical protocol for dealing with crews following a contaminated air event46. In response to this, in late 2005, the DH-funded Toxicology Group at Imperial College asked the independent Committee on Toxicity of Chemicals in Food Consumer Products and the Environment (COT) to conduct a scientific review of the evidence submitted by BALPA and to provide the DfT with advice on research needed on this subject. The COT has met a number of times with interested parties. Not only have they reviewed the data submitted by BALPA but they have requested additional information from various sources such as the CAA and experts. 4.42. In March 2006 the COT asked Dr Sarah Mackenzie Ross, a Consultant Clinical Neuropsychologist based at University College London, to prepare a report describing the results of assessments she had carried out on 27 pilots who had been referred to her for neuropsychological and adult mental health assessment. She found that all but one of the pilots showed “evidence of cognitive impairment but in very specific areas … they were slower to process information, they had fluctuating attention and they had some difficulties with high-level functions like multi-tasking” (Q 136). She looked for alternative explanations to the symptoms presented but found “we had 18 pilots who were impaired and ill and we could find no explanation for why that was the cause … these people are definitely ill; that is beyond a doubt” (Q 136). The COT arranged for an independent review of Dr Mackenzie Ross’s audit by Professor Robin Morris of King’s College Hospital. He concluded that the study “cannot suggest a link and equally does not rule out a link” (Q 296). 4.43. The COT published a statement on 20 September 200747. In its conclusions the COT stated that “it was not possible ... to conclude that there is a causal association between cabin air exposures (either general or following incidents) and ill health in commercial aircraft crew. However, we noted a number of oil/hydraulic fluid smoke/fume contamination incidents where the temporal relationship between reports of exposure and acute health symptoms provided evidence that an association was plausible”. The COT also concluded that “there was insufficient evidence … to recommend additional epidemiological research on any acute health effects”. However, it considered that “overall the potential for cognitive deficits needed further consideration”. 4.44. Sandra Webber, Chairman of the AHWG, told us that cabin air quality and contaminated air events were in the top three priorities of the Group (QQ 229–230). The AHWG, anticipating what the COT would recommend

46 AHWG Minutes 27 October 2004 47 See http://www.advisorybodies.doh.gov.uk/cotnonfood/index.htm AIR TRAVEL AND HEALTH: AN UPDATE 33

(Q 180), had “just begun a ground breaking research project, a world first, using experimental technology” (Q 295) into contaminated air events. Tests will involve simulating and analysing a fume event on the ground and then sampling “around 1,000 flights” to analyse the results. Jim Fitzpatrick MP, told us “we are very much at an early stage but we are putting a lot of effort and resource into addressing this problem because we do acknowledge that there is an issue of concern here” (Q 300). We welcome this research. However, we note that if the incidence of contaminated air events is as low as is claimed by the Government (see below) the sampling of 1,000 flights offers only a remote chance of capturing an event, unless the sampling is targeted at types of aircraft more prone to such events. We therefore trust that the sampling of air in-flight will continue until conclusive results are reached. 4.45. The position adopted by the COT is essentially that the case for any health effects resulting from contaminated air events is unproven, but worthy of further investigation. It is difficult for us to dissent from this judgement, based on the evidence available to us. On the one hand we heard from Dr Nigel Dowdall of British Airways who told us that “I have no evidence to suggest that there is a serious medical problem here” (Q 73). On the other hand claims by pilots, unions, passengers and pressure groups suggest otherwise. The IPA told us that nine of its members have either lost their licences or are under investigation from the CAA due to ill health allegedly caused by contaminated air events. The CAA-funded research mentioned in paragraph 3.6 confirms that contaminated air events can cause acute health effects on air crew. However, opinions differ with regards to long-term health effects. 4.46. Almost all aspects of this subject are disputed by the different sides. The number of contaminated air events is itself a contentious issue. The CAA claims that all fume events are reported and investigated (QQ 298–99). However the unions cited allegations that airlines discourage pilots from reporting contaminated air events (QQ 214–15). The COT estimates, on the basis of information provided by three airlines, that “engineering-confirmed smoke/fume incidents occur in around 0.05 percent of flights but that the incidence may be higher than this”48. Captain Susan Michaelis, a former pilot, who lost her medical certificate in 1999 and has since conducted extensive research into contaminated air incidents, claimed the number to be much higher, and told us that “under reporting of contaminated air events continues with less than 4 percent actually reported” (p 130). 4.47. The chemicals alleged to cause ill health are also disputed. In our original report tri-cresyl phosphate (TCP), and in particular the isomer tri-ortho- cresyl phosphate (TOCP) were evaluated. The organophosphate TCP is present in some synthetic jet engine oils and can be broken down into three sub-groups: the -meta, -para and -ortho isomers of TCP. The -ortho isomers are broken down into three isomers known as tri-ortho-cresylphosphate or TOCP, mono-ortho-cresylphosphate or MOCP and di-ortho- cresylphosphate or DOCP49. The Global Cabin Air Quality Executive claimed that TOCP was in fact the least toxic of the ortho isomers, with DOCP being five times more toxic and MOCP 10 times more toxic than

48 See http://www.advisorybodies.doh.gov.uk/cotnonfood/index.htm 49 HL Deb 8 Dec 2005 col GC132 34 AIR TRAVEL AND HEALTH: AN UPDATE

TOCP. However, we have had no confirmation of this one way or another. Dr Mackenzie Ross likened the profile seen in pilots to that seen in farmers exposed to organophosphates in sheep dip. In contrast Dr Nigel Dowdall of British Airways told us that “I believe the organophosphates element of this is something of a red herring” (Q 83). 4.48. It is clear to us that the evidence base for reaching conclusions on contaminated air events is incomplete, and that more research is needed both to identify the substances produced in a contaminated air event, and to analyse their possible effects on health not just individually but in combination. Dr Mackenzie Ross recommended that research take account of the “potential synergistic effects of the range of different chemicals found in engine oil”, adding: “when certain chemicals are combined, even at safe levels, the end product can be more toxic than what would be predicted from the known properties of each chemical that makes up the mixture” (p 26).

Recommendations 4.49. We recommend that the CAA carries out an awareness campaign aimed at airlines and pilots to highlight the importance of reporting contaminated air events and encourages airlines to follow the spirit as well as the letter of the rules on reporting these events. 4.50. We recommend that the AHWG-sponsored research to identify the substances produced during a fume event be completed urgently. It should be followed up by an epidemiological study on pilots to ascertain the incidence and prevalence of ill health in air crew and any association there might be with exposure to the chemicals identified in the AHWG-sponsored study, paying particular attention to the synergistic effect of these chemicals. 4.51. We recommend that the Government works with manufacturers, airlines and the regulator to take effective action in preventing oil and hydraulic fluid leakages into the aircraft cabin. 4.52. We recommend that a protocol should be made available to health professionals, in particular Authorised Medical Examiners, on how to deal with air crew who suffer contaminated air events. We recommend that airlines, the regulators and the Government work together to improve the support given to pilots claiming to suffer ill health following a contaminated air event.

Fitness to Fly 4.53. There has been a dramatic growth in air travel in the last twenty years. Aviation currently transports two billion passengers annually50 and passenger traffic is projected to grow by an average of 4.9 percent per year51. Although the great majority of the flying public are healthy or have no reason to believe that they are not, there are also now many more travellers with pre-existing health problems. Figures from Stansted Airport show that from 2000 to 2006 the proportion of passengers over the age of 60 has increased from 11 to 17 percent (Q 270). At the same time passengers with certain medical conditions, in particular heart and lung diseases, may not be fit to fly. Health organisations contraindicate flying to individuals with a number of medical

50 See http://www.atag.org/content/showfacts.asp?folderid=430&level1=2&level2=430& 51 See http://www.boeingcapital.com/p2p/archive/12.2006/r1v6y2006_31.htm AIR TRAVEL AND HEALTH: AN UPDATE 35

conditions. The list of such medical conditions is fairly standard across the board. The WHO’s advice is summarised in Box 352. BOX 3 Advice on contraindications to air travel by the WHO Travel by air is normally contraindicated in the following cases: • Infants less than 7 days old; • Women after the 36th week of pregnancy (after 32nd week for multiple pregnancies) and until seven days after delivery; Those suffering from: • angina pectoris or chest pain at rest • any serious or acute infectious disease • decompression sickness after diving • increased intracranial pressure due to haemorrhage, trauma or infection • infections of the sinuses or infections of the ear and nose, particularly if the Eustachian tube is blocked • recent myocardial infarction and stroke (time period depending on severity of illness and duration of travel) • recent surgery or injury where trapped air or gas may be present, especially abdominal trauma and gastrointestinal surgery, cranio-facial and ocular injuries, brain operations, and eye operations involving penetration of the eyeball • severe chronic respiratory disease, breathlessness at rest, or unresolved pneumothorax • sickle-cell disease • psychotic illness, except when fully controlled. The above list is not comprehensive and fitness for travel should be decided on a case-by-case basis.

4.54. Such lists of medical conditions could usefully differentiate between severe conditions, when flying is completely contraindicated, such as very recent gastrointestinal surgery, and those conditions when there is a level of discretion, with individuals entitled to exercise personal responsibility, in light of medical advice—for instance, an infection of the sinuses. 4.55. Airlines and tour operators give out health information when requested and their websites generally include guidelines on fitness to fly and medical clearance before flying. We heard from the airlines that they have systems in place to clear passengers for flying when passengers contact them with specific queries. Ground staff are able to contact remote medical assistance operators if a passenger’s fitness to fly was in question at check-in or at the gate. However, when tickets are purchased no questions are asked with regards to the passenger’s fitness to fly and “much depends on awareness and

52 See http://whqlibdoc.who.int/publications/2005/9241580364_chap2.pdf 36 AIR TRAVEL AND HEALTH: AN UPDATE

self declaration of health” (Q 147). The Head of Health Services at British Airways told us that “we have probably gone as far as we realistically can in terms of stopping people flying who should not” (Q 31). 4.56. Nonetheless existing medical conditions which are not necessarily a problem on the ground may well cause difficulties in flight. A significant proportion of serious in-flight medical emergencies are related to existing medical conditions and in many cases these incidents could have been avoided if there had been awareness by the patient and their doctor of the interplay between their condition and the flight environment. The provision of supplemental oxygen during flight, or the delay of travel until the condition is better stabilised, can only be done if both the patient and doctor are aware of the risks of flying. 4.57. Professor Bagshaw told us that “the number of in-flight medical incidents has not changed” since our original report (Q 148). British Airways provided us with some statistics: “in the year to 31 March 2007, the airline carried 33 million passengers … over the same period the airline recorded 1,700 in- flight medical incidents for which the crew sought the assistance of the MedLink ground-to-air medical advisory service … and there were 50 flight diversions for medical reasons out of the more than 270,000 services operated by British Airways” (p 3). Thomsonfly told us “the defibrillators are used on average about five times a year on board the aircraft and have even been used on a baggage handler who had a heart attack and also on an air bridge to assist a passenger” (p 146). Automated external defibrillators save lives, even if the number is small, and we are therefore pleased to note that all airlines now carry automated external defibrillators on long-haul flights and some airlines carry them on board all their aircraft.

Information and Education 4.58. The amount and quality of information available to the public have changed significantly since the publication of our report in 2000. Not only have contents been updated but also the medium used for disseminating information has changed. When we questioned Ministers in oral evidence on the information available to the public they replied with an enumeration of the websites available for public consultation. This stands in direct contrast to our original recommendations, which concerned updating leaflets and posters for doctors’ surgeries. 4.59. As we mentioned in paragraph 1.6, in response to our 2000 report the airlines have greatly improved the in-flight information provided to passengers; most airlines also now recommend that their passengers do a certain amount of exercise while on the aircraft. We warmly welcome this change. We also note that the information generally available to the public, in large part through the medium of the Internet, has been greatly improved since 2000. But this carries a risk. A substantial proportion of the general public, around 38 percent in the United Kingdom53, do not have Internet access. Among those who have lower than average levels of access to the Internet are the very people who need the most information with regards to existing medical conditions and their general fitness to fly—the elderly. Creative ideas are needed to target such groups. For instance, a leaflet on fitness to fly could be sent to all people applying for a European Health

53 See http://www.internetworldstats.com/stats4.htm AIR TRAVEL AND HEALTH: AN UPDATE 37

Insurance (EHI) card via the post office. And, despite the advance of technology, it might be that our recommendation back in 2000, to put posters on the wall of GPs surgeries, could be a better way to target such people. 4.60. With regards to the content of some of the websites mentioned in evidence, we were disappointed to discover that the AHU website is based on a series of links to other departments and organisations. This is not what we would expect of an organisation intended to be the “focal point” for passenger health. Indeed, we have seen no evidence that websites such as the DH or the Health Protection Agency (HPA) provide links to the AHU website. We note the comments from Dr Ray Johnston that one of his aims “is to try and bring this separate information into one area, i.e. the AHU” (Q 276). We come back to our earlier recommendation that the AHU should work with others in raising its profile among the travelling public, airlines and physicians. 4.61. We would also like to throw in a note of caution with regard to information provided online, which almost inevitably relies heavily on links to other websites. Although disclaimers are common concerning responsibility for the content of other websites, Internet users are not necessarily able to judge the reliability of such content. Publicly funded organisations should therefore make simple initial checks before providing a link to other sources of information, and should conduct regular spot checks subsequently. For example the HPA, which in 2003 took over responsibility for providing travel health advice to the public from the DH, provides a link on its website to the BBC Travel Health section54, which in turn contains the following statement: “In general, the air quality in planes isn’t as good as the air outside, and air filters aren’t always fully effective. This allows bacteria and viruses to spread easily from one person to another, which is why many people come home from their holiday with a cough or cold.” 4.62. This is nonsense. Incorrect information not based on evidence helps perpetuate misconceptions about air travel. We would have preferred to see a link from the HPA and the BBC to authoritative advice provided by the AHU instead. 4.63. We heard repeatedly throughout this inquiry that if a passenger had any concerns about air travel and health or had any existing medical conditions they should contact their GP for advice before travelling. The question that follows from this is whether GPs are adequately trained in aviation medicine and do they keep abreast of the latest guidelines? 4.64. According to Professor Bagshaw, “my experience with lecturing to general practitioners, with teaching GPs, is that there is an amazing ignorance amongst the medical profession about the health effects of flying” (Q 147). Indeed we contacted the Royal College of General Practitioners to find out what proportion of the postgraduate medical syllabus for trainee general practitioners feature aviation health. They told us there is no mandatory training for GPs in aviation medicine. This despite the fact that the BMA, in The Impact of Flying of Passenger Health, has stated: “Healthcare professionals should be appropriately educated concerning the potential risks to health from flying. The BMA believes that

54 See http://www.bbc.co.uk/health/healthy_living/travel_health/before_flighthealth.shtml 38 AIR TRAVEL AND HEALTH: AN UPDATE

undergraduate and postgraduate training curricula should include the relevant aspects. In-depth, specialised courses should be made available for those with a particular interest.” 4.65. At the same time, there is considerable information available to GPs, for example publications such as Managing Passengers with Respiratory Disease Planning Air Travel, published by the British Thoracic Society, The Impact of Flying of Passenger Health from the British Medical Association, and others from the WHO and AsMA. However, these specialist sources of information have not been pooled in a single publication for ease of reference. We also return to the issue of access. Most of this information is provided via the Internet, and we question how accessible it is from a doctor’s surgery when a patient requests clearance to fly from their GP.

Recommendations 4.66. We recommend that the Government and the regulators review the manner in which information on fitness to fly is offered, giving due consideration to their target audience. As the authoritative provider of information for passengers on air travel and health, the Government must ensure that information is available to all, not just people who have Internet access. 4.67. We recommend that the general practitioner postgraduate curriculum should include a basic overview of aviation medicine. Continuing professional development in the form of specialised courses should be made available for healthcare professionals with an interest in this area. 4.68. We further recommend that various specialties such as cardiology, orthopaedics and psychiatry follow the lead of the British Thoracic Society in producing guidelines on fitness to fly with the intention of informing GPs and other healthcare professionals; and that these publications should be made available in electronic form and hard copy to all GPs. In the course of time the collection of these guidelines would form a valuable (paper) reference manual. AIR TRAVEL AND HEALTH: AN UPDATE 39

CHAPTER 5: SUMMARY OF RECOMMENDATIONS

Regulatory arrangements 5.1. We welcome the establishment of the AHU within the CAA. However, we recommend that the AHU and the CAA work together with Government departments and the aviation industry in raising the profile of its work so that it becomes the focus for airlines, passengers and health care professionals in their quest for information on aviation health matters. The AHU should become the body responsible for handling queries and complaints from passengers on health issues and should publish guidelines on how those queries will be handled. 5.2. We agree with the House of Commons Transport Committee that the United Kingdom cannot and must not transfer any further responsibilities from the CAA to EASA until it is clear that EASA is competent to exercise such responsibilities. We recommend that the Government make the strongest possible representations to the European Commission and EASA that the high priority afforded to aviation health in the United Kingdom as a result of the work of the AHWG, the CAA and the AHU must be replicated within EASA. 5.3. We applaud the Government for having taken the steps necessary to make aviation health a priority. The United Kingdom has always been at the forefront in aviation issues and our regulatory arrangements continue to be seen as a model by other countries. However, we recommend: • that the Memorandum of Understanding between the HSE and the CAA, and in particular its Annex 8, should spell out who has specific responsibilities for the health and safety of passengers; • that the HSE and CAA review the interpretation of “occupational health” as it applies to air crew, to ensure that emerging health issues are adequately reflected in regulatory arrangements.

Research 5.4. We recommend that the Government fully support Phase II of the WRIGHT Project including investigations on flight-related factors which may increase the risk of VTE, the relationship between seating and VTE, and effective preventive measures. 5.5. We recommend that the Government bring forward an amendment to Section 23 of the Civil Aviation Act 1982 which regulates the use of information from air crew medical records, so that anonymised data can be extracted and used to carry out epidemiological research projects. 5.6. We recommend that jet lag should be studied as a confounding effect of DVT as part of Phase II of the WRIGHT Project. Other research projects, such as FACE should include jet lag in their studies. We also recommend that the CAA, as the body responsible for the health and safety of air crew while on board an aircraft, commission a study into the possible long-term health effects that jet lag may have on air crew. 5.7. We recommend that in addition to contributing to international research projects, the Government and the Research Councils explore ways to 40 AIR TRAVEL AND HEALTH: AN UPDATE

increase the research capacity in aviation health that exists within the United Kingdom. A strong research base in this country is essential if awareness and understanding of aviation health are to be increased across the wider medical profession. 5.8. We find surprising and frustrating the number of EU-led research projects that have not published their reports. We recommend the Government should take an interest in these projects and if possible expedite the publication of their results.

The cabin environment 5.9. We recommend that the CAA implement the recommendations of its own research into aircraft seating standards, and increase the regulatory minimum distance between seats to at least 28.2 inches. The Government should also make the strongest possible representations to EASA on this subject when they take over responsibility on this issue. 5.10. We recommend that the Government urgently review the level of air passenger duty levied on “premium economy” seating. We further recommend that they explore ways in which the airlines can be encouraged to offer extra space to passengers for a modest premium.

Deep vein thrombosis 5.11. We recommend that the Government and the AHU work together with airlines and others in providing consistent travel advice to passengers on the risks associated with self-medicating with the intention of preventing DVT.

Infectious diseases 5.12. We recommend that the Government and the airlines advise passengers on the proven benefits of good hand hygiene in the reduction of disease transmission and in particular that passenger clean their hands before eating on board an aircraft. In the event of a disease outbreak that could lead to a pandemic, we recommend that as part of their contingency plans airlines flying from affected regions should provide bactericidal wipes and alcohol gels to limit the spread of disease in-flight. 5.13. We recommend that the Government and the regulators limit the amount of time that passengers can remain in an aircraft when the ventilation systems are non-operational to 30 minutes.

Air crew occupational health 5.14. We are reluctant to recommend the modification of CAP 371 until more evidence is presented. We recommend, however, that the Government together with the CAA (including the AHU), the unions and airlines work together to find a way of ensuring that pilots have appropriate rest periods and to monitor fatigue complaints by pilots. We also recommend that the CAA, as the body responsible for the health and safety of air crew while on board an aircraft, commission a study into the long-term effects of fatigue in air crew. 5.15. We welcome the fact that the Aviation Occupational Health and Safety Working Group, chaired by the CAA, is looking into noise-induced hearing loss. However, pending the outcome of this work, we recommend that the AIR TRAVEL AND HEALTH: AN UPDATE 41

CAA work with airlines to review the availability of personal protection equipment so that pilots will be better able to protect their hearing.

Contaminated air events 5.16. We recommend that the CAA carries out an awareness campaign aimed at airlines and pilots to highlight the importance of reporting contaminated air events and encourages airlines to follow the spirit as well as the letter of the rules on reporting these events. 5.17. We recommend that the AHWG-sponsored research to identify the substances produced during a fume event be completed urgently. It should be followed up by an epidemiological study on pilots to ascertain the incidence and prevalence of ill health in air crew and any association there might be with exposure to the chemicals identified in the AHWG-sponsored study, paying particular attention to the synergistic effect of these chemicals. 5.18. We recommend that the Government works with manufacturers, airlines and the regulator to take effective action in preventing oil and hydraulic fluid leakages into the aircraft cabin. 5.19. We recommend that a protocol should be made available to health professionals, in particular Authorised Medical Examiners, on how to deal with air crew who suffer contaminated air events. We recommend that airlines, the regulators and the Government work together to improve the support given to pilots claiming to suffer ill health following a contaminated air event.

Information and education 5.20. We recommend that the Government and the regulators review the manner in which information on fitness to fly is offered, giving due consideration to their target audience. As the authoritative provider of information for passengers on air travel and health, the Government must ensure that information is available to all, not just people who have Internet access. 5.21. We recommend that the general practitioner postgraduate curriculum should include a basic overview of aviation medicine. Continuing professional development in the form of specialised courses should be made available for healthcare professionals with an interest in this area. 5.22. We further recommend that various specialties such as cardiology, orthopaedics and psychiatry follow the lead of the British Thoracic Society in producing guidelines on fitness to fly with the intention of informing GPs and other healthcare professionals; and that these publications should be made available in electronic form and hard copy to all GPs. In the course of time the collection of these guidelines would form a valuable (paper) reference manual. 42 AIR TRAVEL AND HEALTH: AN UPDATE

APPENDIX 1: MEMBERS AND DECLARATIONS OF INTEREST

Members: Lord Broers Lord Colwyn Baroness Finlay of Llandaff Lord Haskel Lord Howie of Troon Lord May of Oxford Lord O’Neill of Clackmannan Lord Patel Lord Paul Baroness Perry of Southwark Baroness Platt of Writtle Earl of Selborne Baroness Sharp of Guildford Lord Sutherland of Houndwood Lord Taverne

Specialist Adviser: Dr Michael Glanfield, Aviation Medicine Specialist and Engineer

Declared Interests: Baroness Platt of Writtle Chartered Aeronautical Engineer employed by British European Airways 1946–49 FRAeS

For further reference, a full list of Members’ interests can be found in the Register of Lords Interests: http://www.publications.parliament.uk/pa/ld/ldreg.htm AIR TRAVEL AND HEALTH: AN UPDATE 43

APPENDIX 2: WITNESSES The following witnesses gave evidence; those marked with * gave oral evidence. Those marked † gave written evidence which is summarised in Appendix 5. Aerospace Medical Association Aerotoxic Association * Air Transport Users Council (AUC) Airbus † Anonymous Association of Flight Attendants Aviation Organophosphate Information Site (AOPIS) * Professor Michael Bagsaw † Captain Colin Barnett-Higgins The Boeing Company † Captain David Bowman * British Air Transport Association (BATA) * British Airline Pilots Association (BALPA) British Airline Pilots Association (BALPA)—Occupational Health and Safety Group * British Airways † Mr Geoffrey Brundrett Building Research Establishment (BRE) † Mr Jonathan Burdon † Captain Yvonne Burford † Mr Alan Carter * Civil Aviation Authority (CAA): † Mr Ray Cockerton * Department for Transport (DfT): * Mr Jim Fitzpatrick MP, Parliamentary Under-Secretary of State for Transport Dr Clement Furlong † Mr Andrew Gibbs Global Cabin Air Quality Executive (GCAQE) † Mr Raymond Godfrey † Mr David Hall Health Protection Agency (HPA) † Professor Malcom Hooper † Mr John Hoyte 44 AIR TRAVEL AND HEALTH: AN UPDATE

Ideal Cabin Environment (ICE) Project * Independent Pilots Association (IPA): Dr G A Jamal Dr Peter Julu † Mr John Kendall † Mr Leonard Lawrence * Dr Sarah Mackenzie Ross † Ms Lucy Mayorga † Ms Claudia Mercer Captain Susan Michaelis † Ms Tracey Morey * Professor Helen Muir NYCO S.A. Mr Ian Panton † Mrs Christine Perdiou † Mr David Phillips * Ms Dawn Primarolo MP, Minister of State for Public Health, Department of Health † Mr Andy Queen Research Institute for Sport and Exercise Sciences † Mrs Samantha Sabatino † Captain Julian Soddy † Dr Moira Somers Ms Christine Standing Thomsonfly † Captain Jonathan Tribe † Ms Joanne Turner Unite the Union * Virgin Atlantic: * Dr William Toff, WRIGHT Project Scientific Executive Committee: AIR TRAVEL AND HEALTH: AN UPDATE 45

APPENDIX 3: CALL FOR EVIDENCE In 2000 the House of Lords Science and Technology Committee published its report Air Travel and Health. The Committee has now decided to undertake a short follow-up inquiry, to be chaired by Lord Broers, to review progress in implementing its recommendations. The Committee therefore invites evidence on the health effects of air travel, with particular emphasis on any relevant new evidence that has emerged since 2000, and on the extent to which Government, regulators and the airline industry have kept pace with such evidence. In particular, the Committee invites evidence on the following questions: • What progress has been made in research into the priority areas identified by the Committee in 2000? Do gaps remain in the evidence base, and, if so, are they being filled? • Have any new health concerns emerged since 2000, and what is being done to address them? For example: - Are steps being taken to address concerns over the role of air travel in the spread of diseases such as SARS or pandemic influenza? • Has new evidence invalidated any of the recommendations made by the Committee in 2000? • How effective has the inter-departmental Aviation Health Working Group been in taking forward the Committee’s recommendations? How are the arrangements for governance and regulation of the industry working? • How successful have the Government been in raising international awareness of passenger and crew health, and in improving international collaboration? • What progress has the airline industry itself made since 2000? For example: - To what extent has the aircraft cabin environment improved? - Are aircraft better equipped, and aircrew better trained, to respond to in-flight medical emergencies? • To what extent has the information supplied to travellers been improved and integrated since 2000? As in the original inquiry, the Committee will not be considering general air safety and the impact of air travel on the wider environment. 46 AIR TRAVEL AND HEALTH: AN UPDATE

APPENDIX 4: SEMINAR

Thursday 21 June 2007 Members of the Committee present were: Lord Broers (Chairman), Lord Colwyn, Baroness Finlay of Llandaff, Lord Haskel, Lord Paul, Baroness Perry of Southwark, Baroness Platt of Writtle, Baroness Sharp of Guildford, Baroness Wilcox. In attendance were Christopher Johnson (Clerk), Elisa Rubio (Clerk), Dr Cathleen Schulte (Committee Specialist), Dr Michael Glanfield (Specialist Adviser).

Presentations

Developments and Progress in Research Since 2000—an Overview: Professor Michael Bagshaw The Committee’s report in 2000 stimulated a number of research projects. The WRIGHT Project was commissioned by the World Health Organisation (WHO) and partially funded by the Department for Transport. Through epidemiological studies, pathophysiological studies and interventional studies the project aimed to confirm the association between air travel and venous thromboembolism (VTE), quantify the strength of the association, identify culpable factors in flight environments and identify and evaluate preventive measures. The main conclusions of the WRIGHT Project were: • for healthy passengers the increase in relative risk when flying was in fact lower than when travelling on other forms of transport; • “hyper-responders” seemed to react to something in airplanes: if an individual had a risk factor the likelihood of him developing VTE increased dramatically after an 8 hour flight; • the longer the flight, including multiple trips, the greater the risk of developing VTE; • travelling by air accentuated other VTE risks; • immobility was an important factor; • there was no difference in the relative risk of VTE if the cabin pressure was reduced; and • those who were very short, tall or overweight were at slightly greater risk. Fifteen organisations from seven European countries participated in the CabinAir project. Questionnaires were sent to the crew of 50 commercial flights and environmental measurements were taken—such as cabin pressure, air and globe temperatures, relative humidity and air velocity. The publication of the full results was imminent but it was suggested that levels of measured air pollutants were similar to other published studies and all levels were below the recommended occupational health limits. There were other research projects such as the Health Effects of Aircraft Cabin Environment (HEACE), which studied the impact on crew members working in the aircraft environment; the Future Aircraft Cabin Environment (FACE), which focused on comfort parameters inside the aircraft; the Ideal Cabin Environment AIR TRAVEL AND HEALTH: AN UPDATE 47

(ICE), which studied the combined health effects of cabin environmental parameters. The Committee on Toxicity was reviewing the health effects associated with contaminated cabin air.

Fitness to Fly: Dr Michael Glanfield The change in passenger demographics meant that the passenger age profile had changed and with it the level of fitness. It was suggested that a significant proportion of serious in-flight medical emergencies were related to existing medical conditions and in most cases the flight environment was an aggravating factor. The question was raised of whether if was reasonable to allow everybody to fly and whether this was fair on passengers, the airlines or travel insurers. Also, who should take responsibility for the decision on who should be allowed to travel. Perhaps for those passengers with existing medical conditions a separate cabin class or separate flights altogether with a lower cabin altitude could be made available with extra oxygen provided. It was suggested that at present no single authority was in charge of fitness to fly. Greater liaison should exist between airlines, travel insurers, doctors and passenger interests groups.

New Health Concerns: Raymond Johnston Three health concerns were highlighted: cabin air, infection and defibrillators. The ICE project—which had completed all its measurements and was analysing data— was unique in that it addressed health and well being. Early results indicated that there was no cause for concern. The Committee on Toxicity was also looking at the health effects of cabin air. Their final statement was expected to be published on 3 July. With regards to the spread of infection the major concern at present was over pandemic influenza. The world currently stood at stage 3 of the WHO pandemic phases, with sporadic cases of H5N1 in humans, but no confirmed human-to- human transmission. Should the virus mutate, and sustained human-to-human transmission, the precursor to a global pandemic, be identified, there were already national contingency plans in place, which covered aviation. Anonymous statistics were presented from three airlines, including a charter airline, which showed that the number of survivors of cardiac arrests when defibrillators were used was very low. An airline which carried an average of 4 million passengers a year had 6 cardiac arrests in a four year period. On 3 of those occasions shocks were given using defibrillators. None of the passengers survived. However pooled data and standard protocols were needed from all airlines.

Aviation Psychology: Professor Helen Muir The longest current direct flights were between 15 to 18 hours covering around 8,000 miles (e.g. New York to Singapore). The question was raised whether on very long journeys (e.g. London to Australia) a quick stop over was enough. A number of factors should be taken into consideration with the design and configuration of very large transport airframes (VLTA) such as the A380, B747 and the blended wing Boeing (which was at the prototype stage): 48 AIR TRAVEL AND HEALTH: AN UPDATE

• Seat design and space: it was difficult for one seat to fit all passengers; • Location and size of exits; • Aisle width: this was largely a comfort issue as it had not been shown to be a factor in emergencies; • Distance to toilets; • Stairs: in particular internal stairs and how they are not supposed to be used in emergencies; • Cabin atmosphere; and • Emergency evacuation slides: the height of the upper decks of VLTAs meant there was a risk of vertigo at the top and injury and congestion at the bottom of the slides. A number of passenger stress factors were mentioned such as claustrophobia and the behaviour of other passengers. Also highlighted as concerns on VLTAs were precautionary evacuations, the spread of fire, cabin crew communications and terrorism.

The Regulatory Framework: Dr Sally Evans The International Civil Aviation Organisation (ICAO) was a UN organisation based in Montreal. It was charged with coordinating and regulating international air travel by establishing rules of airspace, airplane registration and safety. It had 190 contracting states. ICAO’s current interests were cabin air quality, water and food hygiene on board, contingency planning to prevent the spread of disease and medical supplies on board. The European Aviation Safety Agency (EASA), based in Cologne, was gradually absorbing all functions and activities of the Joint Aviation Authorities (JAA) and would assume competence for pilot licensing (including medicals) and operations and safety of third country aircraft in 2010. The Civil Aviation Act 2006 gave the CAA the new function of safeguarding the health of persons on board aircraft and therefore the Aviation Health Unit (AHU) had been set up. It provided reference data on aviation health matters and encouraged and monitored research.

Discussion A lot of new research had been and was being carried out on VTE, most of which was stimulated by the Committee’s original inquiry. Incidence of VTE appeared to be the same in 2007 as it was in 2000. Phase 2 of the WRIGHT project would address the unknowns of phase 1 and would also look at effective interventions. All major airlines had introduced information in their flight magazines and some offered advice on health to passengers over the tannoy system as part of the security briefing before take off. It was noted that 25,000 people died of VTE each year, mainly in hospitals for example following surgery, and the numbers of deaths during or following a flight were tiny in comparison. Most aircraft accidents were unreported in the media and occurred during take off or landing. The most frequent type of accident occurred when an aircraft overran the runway. Effective evacuation measures were imperative. Some 95 percent of aircraft accidents had survivors. AIR TRAVEL AND HEALTH: AN UPDATE 49

The UK was at the forefront of the world in dealing with health issues and should be proud of the way the Aviation Health Working Group (AHWG) had brought together the Government, the airlines, manufacturers, unions and health professionals. It provided an interface with the air transport industry and other interested parties on issues relating to aviation health. The number of UK registered aircraft with HEPA filters had increased as a direct result of the 2000 report. The CAA had responsibility for checking that the filters were maintained regularly as part of the general maintenance schedule. There were regular spot checks. Nine pilots out of 1,500 members of the Independent Pilots Association had either lost their licenses due to health problems or were under investigation. There were no protocols when dealing with crew who complained of having suffered a contaminated air event. There was agreement that such events did happen, but whether they produced long term ill effects needed to be studied. Symptoms reported were non specific and covered broad spectrum; therefore it would be very difficult to undertake an epidemiological study. Some research projects had measured background cabin air, new studies were needed to measure cabin air during a “fume event”, which to date had not yet been achieved. The AHWG was testing measuring devices in conjunction with the Federal Aviation Administration, but the technical challenges of capturing a short-lived “fume event” were still to be solved. It was noted that during the SARS outbreak the infection was not spread by droplets. It was transferred by people touching infected surfaces. Cross-infection was more likely to occur through direct passenger to passenger contact, either at the airport terminal or during the flight, than as a result of air travel generally. With regards to emergency medical equipment on board, it was noted that the standards had not changed since 2000. IATA was the body responsible for making recommendations about the equipment on board. Such recommendations were regularly updated. In general, low cost airlines carried only the statutory minimum equipment while big airlines exceeded the minimum requirements.

Participants were: Andrew Ashbourne, Civil Aviation Division, Department for Transport Professor Michael Bagshaw, Professor of Aviation Medicine, King’s College London Tim Bamber, NEC Member, British Air Line Pilots Association Dr Sally Evans, Chief Medical Officer, Civil Aviation Authority Peter Jackson, Director, Independent Pilots Association Dr Ray Johnston, Aviation Health Unit, Civil Aviation Authority Hanna Madalski, Government Advisor, Airbus Captain Sandy Mitchell, Chairman of Flight Safety Group, British Air Line Pilots Association Professor Helen Muir, Professor of Aerospace Psychology, Cranfield University Dr Mark Popplestone, Head of Medical Services, Virgin Atlantic Airways Sandra Webber, Head of Civil Aviation Division, Department for Transport Dr Ursula Wells, Policy Research Programme, Department of Health 50 AIR TRAVEL AND HEALTH: AN UPDATE

APPENDIX 5: SUMMARIES OF INDIVIDUAL SUBMISSIONS

Note As noted in paragraph 1.13 of this Report several submissions to this inquiry were not treated as evidence or printed. Instead they are summarised below. The full submissions are available for inspection by appointment at the Parliamentary Archives (020 7219 3074).

Summaries 1. A former BAe 146 pilot who wished to remain anonymous said that he was out of work due to ill health. He suffered from toxic encephalopathy and neuropathy including cognitive impairment and dysautonomia. He believed his ill health to be caused by years of daily low level exposure to neurotoxins such as organophosphates. A confidential medical report was enclosed. 2. Captain Colin Barnett-Higgins had flown commercial aircraft for 32 years. During the later part of his career he became more and more fatigued until he could not complete his flight checks successfully. He underwent EEG (body) and MRI scans, blood tests and neuropsychometric examinations. The last test showed discrepancies between ability and performance and in 2000 he lost his license as a result. He noted that, although there were many fume events, nobody realised how dangerous they were and therefore most fume events were not reported in Air Safety Reports. 3. Captain David Bowman flew his last jet aircraft in 2000 after a 42-year career. He continued working as a part-time instructor until 2003 when the CAA medical branch deemed him to be “long term unfit to exercise any privileges of his licence”. Various specialists have diagnosed at different times fronto-temporal dementia, Pick’s disease, Alzheimer’s and Asperger’s syndrome. Tests showed global atrophy of his brain and an executive function score of 18 percent. He felt that his brain functions had been diminished by exposure to organophosphates. Leakage of seals could contaminate aircraft air with synthetic ester based jet engine lubricants which usually contained organophosphates. 4. Geoffrey Brundett, a retired mechanical engineer, expressed concerns at the lack of published data on the effects of cabin altitude. Together with colleagues he had measured actual cabin altitudes for 134 flights since 2001 and found two were above the 8,000 feet limit and 75 percent were under 7,000 feet. He stated that while blood oxygenation for healthy people aged 25 was good up to 7,000 feet, the oxygenation of a proportion of those aged 65 started to decline above 4,000 feet. He called for more research on this area. 5. Jonathan Burdon wished to call the attention of the Committee to the effect of aircraft air quality on the health of air crew and passengers, and in particular to the respiratory disorders which he had observed as a consultant respiratory physician. To his mind there was no doubt that some air crew experienced lung injury which in some cases was very subtle and only detected through sophisticated lung function testing. He listed a number of publications which outlined these disorders. 6. Captain Yvonne Burford had suffered ill health through contaminated air while flying a BAe 146. Since ceasing to fly her health had improved but she still suffered from unexplained headaches which she did not have before flying. She did AIR TRAVEL AND HEALTH: AN UPDATE 51 not believe the Government would allow BAe to be convicted of poisoning aircrew and passengers. 7. Mr Alan Carter flew for 30 years as an airline pilot, including 7,000 flying hours on the BAe 146. At times, during his early morning pre-flight checks, the aircraft cabin would fill with an electric blue haze after starting the auxiliary power unit; this would clear after 10 minutes. He felt that BAe 146 was well known for these problems but that no one thought much of it as it was a common occurrence. In 1998 he felt unwell after a flight with constant flu-like symptoms, fatigue, headaches, nausea and ears ringing. He stopped flying in April 1999. By October he went voluntarily to a private psychiatric hospital for six weeks where he was diagnosed with depression. He did not agree with the diagnosis. In 2004 he underwent nerve conductivity tests which confirmed damage to his nerve system and peripheral neuropathy. He believed his illness was due to organophosphate poisoning. 8. Mr Ray Cockerton was a prematurely retired Boeing 757 pilot. He suffered from poor memory, word-finding difficulties, periods of mild confusion, persistent respiratory infections, chronic fatigue, double vision and tingling fingers. He was invited to take part in the UCL study to examine cognitive function in 27 pilots. Tests showed that large amounts of heavy metals (mercury, arsenic, cadmium, tin, tungsten and nickel) and traces of lindain and nitrosamine were present in his blood. Also, traces of organophosphates were detected in his fat cells. Serum tests revealed that he had acute brain damage and deterioration of the nerve fibres in the extremities consistent with chemical induced nervous injury. The cognitive problems were permanent but the chronic fatigue was getting better. His solicitor was currently pursuing a case of personal injury against his previous employer. He believed that the consistent low levels of air contamination, cumulative over a period of time, had caused his health problems. He was angry that nobody told pilots of the risks associated with flying the 757. 9. In 1998 Mr Andrew Gibbs began to fly the BAe 146. He noticed that the aircraft was quite smelly, particularly in the mornings, but this was regarded as normal. After 18 months he became ill suffering from a sore throat, headaches, aching joints, constant fatigue, muscular weakness, hot/cold flushes, light- headedness and poor short-term memory. Whilst recovering at home his symptoms would diminish but on returning to work he would suffer a relapse. He was dismissed from his employment in late 2000 after only 1,300 flying hours. In 2005 he started flying pressurised aircraft again but after only 100 flying hours he experiences an in-flight malfunction of the cabin air system and the cabin became filled with visible fumes. His ill health returned subsequently and he was still unwell after more than a year. He believed that exposure to poisoned cabin air was the cause of his ill health. At no time was he warned by his employer, BAe or the CAA that the BAe 146 was a high risk type of aircraft. 10. Mr Raymond Godfrey started flying in 1952. From 1987 to 1999 he flew the BAe 146. He recollected mist in the cabin on every flight, more particularly when starting up on the first flight of the day. In 2005 he was referred to a neurological consultant and in July 2006 he was diagnosed with Bulbar motor neuron disease. He believed his condition was a direct result of being in an atmosphere that was contaminated with organophosphates. 11. Mr David Hall flew from 1960 to 1992 as an airline pilot, the last two years of which were on a BAe 146. This aircraft had a continual and distinctive smell resembling dirty wet socks being dried on a radiator, a smell which persisted long after the flight was over. Also, he found operating the BAe 146 excessively tiring. 52 AIR TRAVEL AND HEALTH: AN UPDATE

He retired in 1992 and in 1997 he has diagnosed with Chronic Obstructive Pulmonary Disease. Tests in 2004 revealed that his lung function was some 25 percent of that predicted for his age. In 2005 he had a blood sample analysed and the results were consistent with chemical-induced nervous system injury. 12. Professor Malcolm Hooper sent the Committee a copy of his report entitled “Aerotoxic Syndrome” which he presented at the launch of the Cabin Air Association. 13. Mr John Hoyte flew the BAe 146 from 1989 to 2005. He was constantly aware of fumes, sometimes visible, which lasted approximately 10 minutes. These fumes were more common on the first flight of the day. He experienced progressive ill health, suffering from poor memory, speech difficulties, internal head pressure, chronic fatigue and character change—all of which he believed led to mild depression. In 2004 he was grounded by the CAA and diagnosed with operational stress and post-traumatic stress disorder. In February 2006 Professor Bagshaw officially diagnosed him with chronic stress, which enabled him to get a loss of licence payment. During 2006 he took part in the UCL study programme, which involved testing of blood and tissue. He was very angry at losing his job, income and health. He had started an association to help others who believed that they might have been affected by contaminated air. 14. Mr John Kendall, a 49 year old Training Captain with Thompson, flew the 757 and 767 aircraft. He experienced contaminated air events and suffered light- headedness, nausea and short term memory loss. He believed he had recovered from his symptoms but he no longer had the stamina that he used to have. He was extremely concerned for his long term health. 15. Mr Leonard Lawrence sent a copy of a letter describing the results of medical tests. 16. Ms Lucy Mayorga said that on 10 August 2005 she experienced exposure to organophosphates on an Airbus 329 while working as a flight attendant. Due to the side effects of that incident she suffered from memory problems, depression, anxiety attacks, body aches and chronic fatigue. She had become physically crippled and no one seemed to want to take responsibility. 17. In 2001, at the age of 51, Mr Trevor Mercer had to stop flying due to ill health. He was diagnosed as possibly suffering from depression, then epilepsy and lastly Alzheimer’s disease. However, after further investigations, it had been confirmed that all his problems were consistent with exposure to polluted fumes. 18. Ms Tracey Morey was a former flight attendant who was exposed to contaminated air while working. Although the flight was very short she experienced a headache and nausea. On the return sector she became increasingly nauseous, her hands and face were numb, her heart was racing and the headache returned. After this incident she was off work for six weeks. It took seven years for a tribunal finally to rule in her favour that she had in fact been exposed to a toxic substance. 19. Mr Michael Perdios was diagnosed with left remoralpopliteal DVT following a flight to Cyprus in 1999. He spent five days in hospital receiving treatment with Warfarin and undergoing tests. After receiving permission from doctors to fly back to London he did so on 15 October. He was due to consult his GP four days later but he collapsed at home and died. His wife told us that a post mortem revealed the cause of death was subarachnoid haemorrhage and ruptured cerebral aneurysm. AIR TRAVEL AND HEALTH: AN UPDATE 53

20. Captain David Phillips flew the Boeing 757 for approximately 10 years. During this time he had frequent occurrences of a strong oily wet sock smell just after take off. He was told that this was caused by engineers overfilling the engine oil level overnight. He suffered a number of symptoms such as mouth ulcers, throat irritation, non-migraineous headaches and tremors. His flying licence was suspended temporarily in 1994 and he was finally declared as medically unfit in May 1998. He now suffered from Parkinson’s disease. 21. Mr Andy Queen flew the BAe 146 for 8 years. Normally there would be fumes in the cabin first thing in the morning from the air conditioning system. There were constant smells in the cabin which included wet dog, sweaty socks, and rotten cheese. At times other intermittent smells were present such as oily fumes, exhaust fumes, burning paper and rubber. Mr Queen suffered from acute symptoms such as oily exposed skin, tiredness, concentration difficulties, dry eyes and throat, lack of concentration, tingling limbs and headaches, which would subside within an hour or two after leaving the aircraft. He also suffered chronic symptoms such as hoarseness of voice, memory loss, tremors, emotional changes, lethargy and numbness in three toes. Exhaustive medical testing showed damage consistent with chemical exposure. He had taken swab samples from furnishings and air vents on the flight decks of various BAe 146 aircraft, all of which have tested positive for TCP. 22. Mrs Samantha Sabatino and her family flew from London to Florida in February 2007. During the flight some 40 passengers became ill, including herself and three members of her family. Upon arrival to Florida she was hospitalised suffering from wheezing and crackles in her chest. No infection or viruses were found either in Florida or upon her return home. Her family were still experiencing ill health including violent nausea, tummy cramps, blisters on arms and hands, chest pain, severe headaches, vertigo, insomnia and loss of balance. She had complained to the carrier, XL Airways, who had denied that other passengers had complained of ill health. The Environmental Health Department have not carried out an investigation into the issue. She received unsatisfactory replies from the Health Protection Agency, the CAA and the Air Transport Users Council. She complained of being swept aside and questioned the effectiveness of these organisations. 23. Captain Julian Soddy felt the aircrew community had been let down by the various government-funded research committees. He was a retired airline captain who flew the BAe 146 for 5 years and had been grounded by the CAA due to ill health. He had undergone a series of medical and neurological tests with a diagnosis as having been affected by organophosphate or chemical induced symptoms. He believed there was sufficient evidence to ask the oil manufacturers to exclude dangerous chemicals. 24. Dr Moira Somers was a medical practitioner registered with the West Australian Medical Board. Since 1999 she had seen 39 flight crew who had reported exposure to contaminated cabin air while on the BAE 146 and other aircraft. In 2005 she reviewed all of the consultations and produced a paper titled “A General Practitioner’s Experience with Cabin Air Problems”. 25. Captain Jonathan Tribe had been a qualified pilot for 26 years, for the last 19 of which he had been employed by one large UK charter airline. In this capacity he had predominantly flown the Boeing 757 and 767. Over his career he had been aware of repeated exposure to engine oil fumes and has often reported it to his employer and the CAA. On 29 February 2002 while flying the B757, the left engine suffered technical failure that allowed large quantities of pyrolysed engine 54 AIR TRAVEL AND HEALTH: AN UPDATE oil to enter the air conditioning system. Within weeks he developed a skin rash on his tongue and acute sensitivity, severe digestive symptoms, fatigue and cognitive deterioration. In 2006 he underwent blood and fat tests as well as a cognitive function test that showed impairment. He was still a full time airline pilot and confirmed that he was still exposed to engine oil fumes on a regular basis. He had written to the CAA and his employer on this issue but neither party recognised this as a health or flight safety issue. 26. Ms Joanne Turner worked in aviation for 22 years in Australia. During this time she was exposed to oil leaking into the air supply of the aircraft. In March 2000 she had her lungs washed out because of exposure to a fume event. She now had a medical condition called Reactive Airways disease. AIR TRAVEL AND HEALTH: AN UPDATE 55

APPENDIX 6: LIST OF ACRONYMS AND ABBREVIATIONS

Organisations AEA Association of European Airlines AFA International Association of Flight Attendants AHU Aviation Health Unit AHWG Aviation Health Working Group AOHSSG Aviation Occupational Health and Safety Steering Group of the CAA AOPIS Aviation Organophosphate Information Site ASHRAE American Society of Heating, Refrigerating and Air-Conditioning Engineers AsMA Aerospace Medical Association AUC Air Transport Users Council BALPA British Air Line Pilots Association BATA British Air Transport Association BBC British Broadcasting Corporation BMA British Medical Association BRE Building Research Establishment CAA Civil Aviation Authority CASA Civil Aviation Safety Authority of Australia CDC Centre for Disease Control COT Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment DfT Department for Transport DH Department of Health DTU Technical University of Denmark EASA European Aviation Safety Agency ECAC European Civil Aviation Conference ETF European Transport Workers Federation FAA Federal Aviation Administration FCO Foreign and Commonwealth Office GCAQE Global Cabin Air Quality Executive HPA Health Protection Agency HSE Health and Safety Executive IAQG International Aerospace Quality Group IATA International Air Transport Association ICAASM International Academy of Aviation and Space Medicine 56 AIR TRAVEL AND HEALTH: AN UPDATE

ICAO International Civil Aviation Organisation IEH Institute for Environment and Health IFALPA International Federation of Air Line Pilots’ Association IPA Independent Pilots Association JAA Joint Aviation Authorities NaTHNaC National Travel Health Network and Centre NIOSH National Institute for Occupational Safety and Health PMETB Postgraduate Medical Education and Training Board UCL University College London WHO World Health Organization

Other AED Automatic External Defibrillator AME Authorised Medical Examiner AN Airworthiness Note ANO Air Navigation Order, CAA’s principal regulatory instrument APIS Advance Passenger Information System APU Auxiliary Power Unit BAe 146 British Aerospace 146, a type of aircraft CAP Civil Aviation Publication CAQ Cabin Air Quality CHIRP Confidential Human Factors Incident Reporting CMO Chief Medical Officer CR Cosmic Radiation DOCP Di-Ortho-Crecyl phosphate, an isomer of TCP DVT Deep Vein (or venous) Thrombosis EHI European Health Insurance FACE Friendly Aircraft Cabin Environment FTF Flight Test Facility GP General Practitioner HEACE Health Effects of Aircraft Cabin Environment HEPA High Efficiency Particulate Air, as a descriptor of filters ICE Ideal Cabin Environment IHR International Health Regulations MOC Memorandum of Cooperation MOCP Mono-Ortho-Cresyl Phosphate, an isomer of TCP MOR Mandatory Occurrence Report AIR TRAVEL AND HEALTH: AN UPDATE 57

MoU Memorandum of Understanding MSDS Material Safety Data Sheet OP Organophosphate OPIDN Organophosphate-Induced Delayed Neurotoxicity PAO Personal Air Outlet SPME Solid Phase Micro-Extraction Device TB Tuberculosis TCP Tri-Cresyl Phosphate, an anti-wear additive in aviation lubricants TOCP Tri-Ortho-Cresyl Phosphate, an isomer of TCP UV Ultra Violet Light VOC Volatile Organic Compound VTE Venous Thrombo-Embolism, the term for the full syndrome of both initial DVT and any subsequent embolism WRIGHT the World Health Organization Research Into Global Hazards of Travel 3844421001 Page Type [Ex 1] 30-11-07 13:07:50 Pag Table: LOENEW PPSysB Unit: PAG1

Minutes of Evidence

TAKEN BEFORE THE SELECT COMMTTEE ON SCIENCE AND TECHNOLOGY TUESDAY 26 JUNE 2007

Present Broers, L (Chairman) Howie of Troon, L Colwyn, L Patel, L Finlay of Llandaff, B Perry of Southwark, B Haskel, L Selborne, E

Memorandum by British Airways Plc

Introduction 1. British Airways welcomes the opportunity to submit evidence to the follow-up Science and Technology Committee inquiry into air travel and health. The airline was a contributor of both written and oral evidence to the original inquiry in 2000, and was pleased to facilitate a visit by the Committee to the British Airways Maintenance base at CardiV Airport as part of its research. 2. The health, safety and security of passengers and employees are the primary concerns of British Airways. In the year to 31 March 2007, the airline carried 33 million passengers and employed 43,000 staV, including 18,000 pilots and cabin crew. Over the same period the airline recorded 1,700 in-flight medical incidents for which the crew sought the assistance of the MedLink ground-to-air medical advisory service. 3. British Airways has always taken its responsibilities very seriously in matters of health and safety and provides active support to a number of independent and international aviation medical organisations. We also work closely with industry groups, medical professionals and regulatory agencies to ensure we deliver the highest levels of care to our customers and employees. The airline has long been a leader in innovation in areas to enhance the health and safety of passengers and crew. 4. As we stated in 2000, we believe there is little independent scientific evidence to support any view that there is adverse eVect on the health of passengers or crew members from travelling in a pressurised aircraft cabin. The cabin is the normal place of work of the 15,000 cabin crew members employed by British Airways and we see no trends in sickness rates or causes which would indicate a link.

SpecificIssues 5. The information submitted by British Airways to the original inquiry in 2000 remains relevant. We believe the information given by HM Government in response to the same inquiry also remains relevant. 6. We oVer the following comments in response to the specific questions posed in the Call for Evidence of the Committee’s Inquiry

What progress has been made in research into the priority areas? 7. Deep Vein Thrombosis (DVT). Since the Committee’s original report, the World Health Organisation (WHO) conducted a major study into the eVects of air travel and DVT. The WRIGHT study confirmed the belief that the risk of DVT in air travel is due to prolonged seated immobility and that this is no diVerent to that found for other causes of prolonged immobility. There is not a risk specifically attributable to air travel. Research commissioned by the UK Aviation Health Working Group (AHWG) also examined population attitudes to DVT risk and the sources of information used. This led to recommendations on consistent sources of information and use of terminology by those providing information to passengers. 8. Cabin Air. Several recent studies have been conducted into cabin air quality, including the European Union’s Cabin Air project and the United States’ ASHRAE study. Both have confirmed the results of previous studies that cabin air quality is generally at least as good as, and often better than, that found in domestic or oYce environments, other than the known issues of low humidity and reduced level of air pressure. 3844421001 Page Type [E] 30-11-07 13:07:50 Pag Table: LOENEW PPSysB Unit: PAG1

2 air travel and health: evidence

The UK CAA is a participant in the EU Ideal Cabin Environment (ICE) project which aims to build on the previous research and deliver final outcomes and recommendations. 9. Contamination of cabin air. The AHWG is addressing the concerns of a small number of individuals and organisations about the possible acute and long term health eVects of contamination of the cabin air supply, particularly on flying crew. The Committee on Toxicity (COT) is undertaking a review of the existing evidence and the AHWG Research Sub-Group is commissioning research this year to sample cabin air. The research will also use new technology to try to capture data on an actual contamination incident. 10. We consider this a very good example of the collaborative work taking place within the UK of the AHWG, with input from the aviation industry, the Trade Unions and several Government Departments. 11. Evidence base. It will always be possible to identify areas where further research would be interesting and/ or useful. However, there is little evidence that air travel leads to adverse health eVects and, therefore, little evidence that research in this area should necessarily be a priority for funding.

Have any new health concerns emerged? 12. Infectious disease. The SARS outbreak in 2003 highlighted the potential role of air travel in the global spread of infectious disease, in that those who appear well but are incubating an infection can travel large distances in a short time. In response to the outbreak, eVective relationships were developed at that time between the WHO, the International Civil Aviation Organisation (ICAO) and International Air Transport Association (IATA) to address the issues and provide guidance on management of communicable disease in air travel. There have been notable outcomes as a result of the continued collaboration between WHO, ICAO and IATA. These include recommendations for airlines and airports on planning for pandemic flu; guidance for cabin crew, ground staV and cleaning staV on the management of an incident involving a person with a suspected communicable disease; revision of the WHO guidance on “Air Travel and TB” and relevant aspects of the International Health Regulations. With regard to the retention of passenger’s information, British Airways has policy and procedures in place to facilitate the provision of data and other support to the public health authorities, based on the processes advocated by the WHO.

Cabin air contamination. See above

Effectiveness of AHWG 13. The AHWG has proved eVective in bringing together representatives of Government, the aviation industry, airline staV and passengers in a forum in which issues relating to air travel and health can be raised and discussed. The main outputs have included the provision and exchange of information; evidence reviews, the prime example being the COT involvement in the contaminated cabin air issue; and the commissioning of research. 14. The UK commercial aviation industry is represented at the AHWG by two representatives, Dr Nigel Dowdall, Head of Health Services for British Airways, and Dr Mark Popplestone, Head of Medical Services for Virgin Atlantic. Both are also members of the AHWG research sub-group.

International awareness 15. Since 2000, there has been a considerable expansion in interest in air travel and health and also in collaboration between the various groups. Examples of these include the establishment of the European Civil Aviation Conference (ECAC) Airline Passenger Health Issues Working Group, which brings together representatives of the European Aviation Authorities with representatives of industry (Association of European Airlines—AEA, IATA), flying crew (European Transport Workers Federation—ETF, IFALPA), other regulators (US FAA, Transport Canada, ICAO), and aviation medicine (Aerospace Medical Association—AsMA); and the ICAO Air Passenger Health Multi-Disciplinary Working Group. 16. Dr Nigel Dowdall of British Airways is a member of the IATA Medical Advisers Group. In this capacity, he was one of two industry representatives who contributed to the revision of two WHO publications, namely ‘Tuberculosis and Air Travel’ and the air travel chapter in “International Travel and Health”. 3844421001 Page Type [O] 30-11-07 13:07:50 Pag Table: LOENEW PPSysB Unit: PAG1

air travel and health: evidence 3

Aircraft cabin environment improvements 17. The progressive replacement of ageing aircraft with newer aircraft has led to incremental improvements in cabin environment. For example, the highest eYciency HEPA filters are the standard fit on all new commercial aircraft. Aircraft manufacturers are continually seeking improvements for their products. At this time, both Boeing and Airbus are evaluating strategies—and any associated benefit—to improve humidity levels. They are also exploring alternative sources to engine bleed air for the cabin air supply and the potential benefits of a reduction in the maximum operating cabin altitude.

In-flight medical emergencies 18. There is no evidence to suggest that the JAA regulatory requirements for aircraft medical equipment and cabin crew medical training are inadequate. Nevertheless, British Airways and other airlines are continually working to develop their equipment and training in light of medical advances. Together with Virgin Atlantic, British Airways has jointly sponsored research to confirm the eYcacy of cardiac resuscitation using an “astride” technique more suited than traditional methods for use in the aisle of an aircraft. 19. Defibrillators have been installed on all British Airways aircraft since April 2000, and are still carried on all aircraft, together with crew trained in how to use them. 20. British Airways has used the MedLink service since 1998 as the provider of advice on the management of in-flight emergencies and also of “gate clearance” before passengers embark. In the year to the end of March 2007, we consulted MedLink on 1,700 in-flight medical incidents, out of some 33 million passengers carried. During this period there were 50 flight diversions for medical reasons, which is fewer than 1 in 5,400 of the more than 270,000 services operated by British Airways.

Information to Travellers 21. Most airlines provide health information for passengers, particularly on their websites. Collaboration between IATA and WHO in revising the WHO information on “Air Travel and Health” and use of common sources of information such as that on the AsMA website have helped to ensure consistency of information and advice. In the UK, the Aviation Health Unit of the CAA provides a focal point for passengers, media and other interested parties. 22. British Airways has published health information on its website since 2000. The comprehensive information is found under the “Health and Well Being” page of the information section of our website. This is complemented on-board by our video and audio presentations and by well-being guidance in the in-flight magazine High Life. 23. The website provides links to other organisations and sources of information where relevant, and also oVers guidance on a range of medical conditions and compatibility with flying. Our website advises customers with specific queries about their fitness to fly to contact the British Airways Passenger Medical Clearance Unit and for those with special needs to contact our reservations team. Full contact details are given. 24. British Airways also provides information to medical professionals through its Your Patient and Air Travel publication. This is reviewed and updated regularly to ensure it reflects the latest medical advice and information. In addition, our in-house team of doctors and occupational health nurses frequently contribute at conferences and post-graduate meetings. Dr Dowdall was the co-author of the British Medical Association Board of Science and Education publication The Impact of Flying on Health: A Guide for Health Professionals published in May 2004.

Information for Crew and Employees 25. British Airways has conducted and/or participated in several research projects in recent years, including a flight crew mortality study. We have various means of identifying and responding to issues of concern raised by our crew, through staV forums; safety data collection and monitoring; and our in-house occupational health service. 26. As with all commercial pilots of UK airlines, our flight crew regularly undergo CAA medical examinations with approved medical examiners to ensure they are fit to fly. 27. Detailed information on a range of health issues is available to all employees on the airline’s intranet website, which also includes links to the main British Airways health pages. 3844421001 Page Type [E] 30-11-07 13:07:50 Pag Table: LOENEW PPSysB Unit: PAG1

4 air travel and health: evidence

Summary 28. British Airways believes there have been significant advances in the area of air travel and health in the years since the House of Lords Science and Technology Committee published its report into the subject in 2000. The establishment of the Aviation Health Working Group was a major factor in the improving understanding of the issues and informing the industry, consumers and Government public policy. It has led to the creation of the Aviation Health Unit which provides timely and accurate advice to Government on a wide range of health issues. 29. Several studies have been undertaken into various aspects of air travel, in particular into DVT, and these have helped to allay public and travellers’ fears and misconceptions about aviation. Information is more widely available and the medical profession is better informed about the impact of flying on passenger and patient health. 30. The safety and health of customers and employees are vital to British Airways and to the wider aviation industry. We welcomed the Committee’s report in 2000 following a thorough and extensive inquiry that sought evidence and comment from acknowledged medical experts and aviation health professionals. We hope and expect the follow-up inquiry to be of a similar standard. June 2007

Memorandum by Virgin Atlantic Virgin Atlantic was pleased to respond to the previous consultation process prior to the publication of Air Travel and Health and we welcome this opportunity to respond to the follow-up inquiry by the House of Lords Science and Technology Select Committee. Since the original report, much progress has been made. The Department for Transport’s Aviation Health Working Group has been eVective in raising and addressing issues of concern, promoting research and making recommendations. The establishment of the Aviation Health Unit is also a welcome innovation which has been able to provide an expert, objective and impartial perspective on aviation health. There are areas that are still “work in progress”, but the nature of scientific research means that it would be unrealistic to expect all the questions to have been resolved. The eVects on health of travelling by air have at times resulted in disproportionate levels of concern within the media. Every day, millions of people of varying ages and states of health travel by air, sometimes for very long distances, without any trouble at all. Of course no mode of travel is risk free and every year a small minority of our passengers do experience some form of ill health, but very few of these are caused by the aircraft environment itself. Last year Virgin Atlantic carried 4.94 million passengers, out of which there were only 28 significant reported medical emergencies, many of these in passengers with existing (and undisclosed) medical problems. Virgin Atlantic takes its responsibility towards the health of both its passengers and staV very seriously and actively promotes good health via our website, in-flight media, reading material as well as our dedicated Special Assistance Team and ground to air medical advice. It is clearly not in our interest to endanger the health and safety of our passengers.

AHigherProfile forHealth

1.15 Paragraph 8.41 Virgin Atlantic notes the recommendation by the Committee that the Department of Health should monitor the use of the revised version of Health Information Overseas Travel. As this document was published in 2001, we would welcome an updated version, and recommend that it is reviewed more often than at five year intervals.

DeepVeinThrombosis

1.16 Paragraph 6.25 A number of research studies have been published in recent years, including those conducted under the auspices of the WRIGHT study (See Annex A). Overall these support the view that the risks of DVT and flying are similar to those associated with other forms of long distance travel. Furthermore, it appears that any increase in risk is principally in those passengers with other risk factors. Research into the eVectiveness of preventive measures would be useful but should also include train, coach and car passengers. 3844421002 Page Type [O] 30-11-07 13:07:50 Pag Table: LOENEW PPSysB Unit: PAG1

air travel and health: evidence 5

1.17 Paragraph 6.29

Virgin Atlantic already provide information on DVT via our Special Assistance section on our website. If a passenger indicates to our Special Assistance Team that he or she has previously experienced a form of disorder relating to circulation, written information is provided on the prevention of blood clots. This information advises passengers to exercise their legs regularly on the aircraft; to avoid falling into a deep sleep; avoid sleeping pills and drink plenty of fluids but to avoid excessive alcohol consumption. If they have specific risk factors we suggest that they consider wearing professionally fitted below knee compression stockings; and they are encouraged to discuss with their GP whether other measures are needed to avoid the risk of Thrombosis. Information to passengers regarding their health, including DVT, is also available on our in- flight entertainment system and in-flight publications, brochures provided at check-in, inflight publications and onboard announcements by the crew.

AirQuality

1.26 Paragraph 5.50

Virgin Atlantic operates and maintains its aircraft in accordance with the manufacturers’ and regulator’s requirements. The Committee’s recommendation for airlines to collect cabin environment data would not be quite as straightforward as is suggested. Such measurements needed to monitor the data are complicated as evidenced by the long deliberations of the Aviation Health Working Group into allegations of contaminated cabin air. We support the eVorts of the Department for Transport Aviation Health Working Group and the Committee on Toxicity, and we believe it would inappropriate to take this recommendation any further until they have reported their findings.

1.29 Paragraph 4.47

Virgin Atlantic already has ozone converters on all our aircraft and we have done so for many years.

Transmission ofInfection

All Virgin Atlantic aircraft have first aid and emergency medical kits including equipment such as intravenous sets, catheters, airways and emergency drugs. Unlike many other airlines, Virgin Atlantic supplies bottled oxygen free of charge to passengers with medical conditions that require it.

1.31 Paragraph 7.33

Virgin Atlantic has 24-hour onboard specialist medical advice via satellite, telephone or radio communications to MedLink (MedAire), based in Phoenix, Arizona. Medaire have many years experience in providing remote medical advice and are regarded as a leader in the field. Medical professionals and crew members working under their instructions are indemnified by the airline (although one of the major UK medical indemnity providers has no recorded case where a medical professional has been sued by a passenger). Virgin Atlantic ground staV are fully trained to recognise ill passengers. Guidance on this is also supplied in Virgin Atlantic’s Air Service Manual.

1.32 Paragraph 7.22

It is Virgin Atlantic’s practice to keep air conditioning in operation on the ground whilst passengers are onboard wherever possible. It should be noted that to do so requires the auxiliary power unit to be running or to have a supply of ground power. 3844421002 Page Type [E] 30-11-07 13:07:50 Pag Table: LOENEW PPSysB Unit: PAG1

6 air travel and health: evidence

1.33 Paragraph 7.40

Virgin Atlantic already holds extensive passenger information via the APIS and PNR data systems. APIS data contain passengers’ passport information (some countries, such as the US, require more detailed APIS data that include a passenger’s first night of stay) and PNR data contain information of the passengers booking. Any notification by a passenger of a pre-existing health condition would also be included within the PNR data. Virgin Atlantic holds both APIS and PNR passenger data for at least five years. In our view there is no need to add an extra system of data collection when there is already a more than adequate system in place.

AirFiltration

1.36 Paragraph 7.26

Virgin Atlantic aims to ensure that passengers onboard its aircraft receive the highest quality of air practicable. All of our aircraft ventilation systems meet the Civil Aviation Authority’s requirements and all our aircraft have High EYciency Particulate Air filters (HEPA) as standard. Re-circulated air is passed through a HEPA filter to remove 99.9% of all pathogenic bacteria and viruses. The filter manufacturer states that HEPA filters will remove viruses (including the influenza virus) and bacteria (including SARS and TB). The design of modern aircraft air conditioning systems mean that airborne circulation of infectious diseases through the cabin is extremely unlikely and there is no evidence to support the suggestion that such filters cause cross- infection. Of course direct person to person spread to adjacent passengers is still possible in common with any other public place.

In-flightMedicalEmergencies

1.41 Paragraph 7.77

We see no need for further regulation to make it compulsory to carry Automatic External Defibrillators (AEDs). Virgin Atlantic has chosen to exceed all required standards for medical kits for passengers and for training of staV. Virgin Atlantic was one of the first airlines to place defibrillators on all its aircraft in 1992. We do not believe that the provision of AEDs should become mandatory and the decision should remain with the airline. Virgin Atlantic provides an excellent standard of training in first aid, emergency life support, occupational health issues and aviation physiology. All new cabin crew complete a five-day training course and receive recurrent training throughout their career. In our view, crew training and expert ground-to-air medical advice are probably the most important and beneficial aspects of in-flight medical care.

Research

1.43 Paragraph 9.3

Research that has already been undertaken on DVT has been helpful and has assisted in putting the risk of DVT, associated with flying, into perspective.

1.44 (b) Paragraph 9.5

The option to pre-book seats with additional legroom is not always appropriate. Priority for such seats is given to people travelling with infants and people with significant disabilities. The allocation of exit row seats is only given to people who are physically able to assist in an emergency. On a separate point, there is anecdotal evidence of passengers being oVended by questions asked about their physical health. For example, legislation in the United States prevents our staV from asking direct question of this kind. In order to avoid such problems, it is far better to make information freely available to passengers, not just by airlines, but airports, governments and other such relevant bodies. 3844421003 Page Type [O] 30-11-07 13:07:50 Pag Table: LOENEW PPSysB Unit: PAG1

air travel and health: evidence 7

1.46 Paragraph 9.8 Virgin Atlantic actively promotes good health to our passengers. Onboard all Virgin Atlantic flights an announcement is made by cabin crew encouraging passengers to move their legs and stretch frequently. Passengers are informed that they can find tips on seated exercises and jetlag in our in-flight publication. We also encourage our passengers to walk around the cabin once the fasten seat belt signs have been switched oV and remind them in doing so to be careful of any unexpected turbulence.

Conclusion In Virgin Atlantic’s view, our responsibility is to inform our passengers and our staV on matters of health without sensationalising the issue. As the statistics regarding medical emergencies show, the overwhelming majority of passengers travel by air safely without cause for medical concern. Therefore it is our conclusion that airlines’ eVorts are best served by targeting the passengers who have greater susceptibility to medical problems rather than applying a crude blanket approach. At the same time, Virgin Atlantic will continue to encourage all our passengers and staV to take care of their health whilst onboard our aircraft. 18 June 2007

Examination of Witnesses Witnesses:DrNigelDowdall, Head of Health Services, British Airways,DrMarkPopplestone, Head of Medical Services, Virgin Atlantic andMrRogerWiltshire, Secretary General, British Air Transport Association (BATA), examined.

Q1 Chairman: Thank you very much for coming to of the year 2000 airlines in the UK flying long haul see us, and could I welcome members of the public. services had plenty of information available for There is an information note on this inquiry for you customers. We have maintained that information if you wish to have it. It is easiest if we start by you and monitored it through the period, including after introducing yourselves, please. reviewing the jointly funded study that the industry Dr Dowdall: I am Dr Nigel Dowdall, I am Head of funded together with the Department of Health, the Health Services for British Airways. study into DVT perception in the public, and we have Mr Wiltshire: I am Roger Wiltshire, I am Secretary reviewed our information following that work. We General of the British Air Transport Association. also now have a much more modern fleet of aircraft Dr Popplestone: I am Dr Mark Popplestone, I am in the UK fleet and as newer aircraft come on stream Head of Medical Services for Virgin Atlantic. in the future we see improvements in technology which means more reliable systems and processes in Q2 Chairman: Thank you for being here. Would you the aircraft. One issue I would like to raise is as like to make any opening statement or shall we go regards passenger comfort, which was an issue in the straight into the questions? original inquiry. Since the year 2000 UK airlines have Mr Wiltshire: My Lord Chairman, I would just like introduced product enhancements on long haul to say a few words. Thank you for inviting us and we services so that most airlines, charter and scheduled, welcome your inquiry. We here have been in the now oVer a premium economy, or economy plus industry for many years and were involved with the product, where passengers can get additional original inquiry in 2000 and ever since then with legroom for a modest premium, but sadly that groups such as the Aviation Health Working Group, category of product is defined as the high rate of air so we look forward to contributing and hope we can passenger duty and since air passenger duty was help you this morning. doubled on 1 February it has had an influence on that market; we find that very unfortunate for passengers Q3 Chairman: Thank you. Let me ask the first who wish to purchase at a modest premium some question then which is perhaps the main point that extra legroom. We are talking to the Treasury and we are trying to gather in this inquiry, and the hope we can have that product type categorised as a question is what progress have airlines made in standard rate of air passenger duty. improving flying conditions for passengers and crew since 2000? Q4 Chairman: What are the consequences of having Mr Wiltshire: I am sure my colleagues will want to it categorised as a premium product? add specific issues, but I believe that during the year Mr Wiltshire: The long haul air passenger duty was 2000 the airlines made a considerable move on the lowest rate, £20, and the premium rate of air advising passengers on health risks, in particular the passenger duty was £40 up until 1 February. Those need to do exercises, the risks of DVT and a lot of the rates have now doubled, so for passengers changes occurred during that year, so that by the end purchasing this extra legroom they now have to pay 3844421003 Page Type [E] 30-11-07 13:07:50 Pag Table: LOENEW PPSysB Unit: PAG1

8 air travel and health: evidence

26 June 2007 Dr Nigel Dowdall, Dr Mark Popplestone and Mr Roger Wiltshire

£80 each just in UK tax to take the privilege of that levels that you will find in cabin air are lower than product, and that is having an eVect on the market, you would find in a typical oYce or domestic we believe, and we feel it is appropriate for that environment. It is very, very good and more than product to be categorised as a standard rate of air adequate for the task. passenger duty rather than the rate that applies to first and business class seating, which is an entirely Q8 Lord Colwyn: I had imagined that they are the diVerent product, often with beds or similar-size sort of thing you might change weekly or monthly, seating areas. but in fact we heard last week that it is annually or bi- annually. How come an eYcient filter like that can Q5 Chairman: You say that the new planes provide last quite so long? I do not understand that. better facilities. Have there been significant changes Dr Dowdall: I am told—again, I am not a filter in, for example, the air supply systems in the newer expert—that actually the filters become slightly more planes? eYcient as they come into use in that you actually Mr Wiltshire: The filtration systems now are all up to reduce the size of some of the gaps within the the highest HEPA filter standards—again, my structure of the filter so that it becomes slightly more colleagues can probably answer in more detail here. eYcient. Clearly, the manufacturers of the filters Some of the oldest planes some years ago were still design them, assess them and they recommend a operating with lower quality filters, but those oldest period of maintenance and when they should be planes as I say have been phased out in the last few changed, and the airline practice would be to change years and so we are now operating a fairly consistent those filters in accordance with the manufacturer’s fleet as far as air filtration is concerned. recommended schedules. The main impact you will see of deteriorating performance is actually the Q6 Earl of Selborne: British Airways in their impact on the airflow. evidence say that “the highest eYciency HEPA filters are standard fit on all new commercial aircraft.” Does that mean that they are the most eYcient filters Q9 Chairman: May I ask you how eVective, in your and what would be the filters that the older aircraft experience, has the Aviation Health Working Group would have and how would they compare? been; how frequently do you take part in its meetings Dr Dowdall: As an example the highest eYciency and does it embrace a suYciently wide spectrum of HEPA filters, High EYciency Particulate Filters are interests and opinions? described as 99.99% eYcient and those are the Dr Dowdall: I was involved from when the group was standard of filter that you would find, for instance, first set up. Putting it in context, the original House used in a hospital operating theatre air circulation of Lords report has stimulated a much greater system. As an example of an older type of filter that interest in passenger and crew health, and that is seen has been installed in the past on the Boeing 737, that not just in the Aviation Health Working Group and was a diVerent type of filter, that was equivalent to the Aviation Health Unit, it is seen in the activity that approximately a 95% eYcient filter. Again, to put is taking place in Europe and in the world. In terms that in context, that is the sort of standard of filter of the Aviation Health Working Group its functions that you would expect to find in a hospital intensive evolved; initially, every other meeting was what was care facility, so although the highest eYciency ones described as exclusive so it did not involve the non- clearly give you the best eYciency, even the less government partners, but that has recently changed eYcient ones actually compare very well in terms of so that we attend all of the meetings. It has a very environmental protection. If you buy a new Boeing broad spread, including government departments, or a new Airbus that has a recirculation system then passenger groups, staV representatives, the TUs and it will come fitted with a standard 99.99% highest the industry. It works very eVectively; I guess like eYciency filter. most people I was perhaps slightly sceptical of how it would work when it was first set up but I have been very impressed with the work that has happened and Q7 Lord Haskel: What is the 0.1 that gets through that is a tribute particularly to the chairs of the group the filters? who have driven the direction. Dr Dowdall: 0.01. I am not an engineer or a Mr Wiltshire: I have nothing to add to that. technologist, but it has to do with how they measure the eYciency of these particular types of filter. I guess it is a reflection of the fact that no filter could be Q10 Chairman: From your point of view it is absolutely 100% eYcient, otherwise you would not available to you and you can get to speak to them get adequate airflow through. 99.99% eYciency is whenever you want. extremely high and from the studies that have been Dr Dowdall: Yes, it has created a very good working done of cabin air quality, if you look at the microbial tool and, with its research sub-group, is really driving load in the air—viruses, bacteria, fungi—then the things forward. 3844421003 Page Type [O] 30-11-07 13:07:50 Pag Table: LOENEW PPSysB Unit: PAG1

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26 June 2007 Dr Nigel Dowdall, Dr Mark Popplestone and Mr Roger Wiltshire

Q11 Chairman: Mr Wiltshire, you mentioned the we would be quite loathe to try and impose another literature but can I ask formally what changes have ban on people. airlines made to the literature and information that Lord Howie of Troon: Can I express some relief? they provide to passengers since our previous report? Mr Wiltshire: The information is usually involved in Q13 Chairman: Can we go back to aspirin a minute? diVerent channels, firstly on websites where You said the information on aspirin was muted; does passengers booking that way can find out something that mean it is still there or has it been eliminated? about looking after yourself during the flight, and the Mr Wiltshire: We leave it to people to get medical information contained in that sort of section covers advice from their doctor or medical adviser. not just things like doing exercises and maintaining Dr Popplestone: The thing about aspirin is that the some mobility in the aircraft, it is also to do with evidence of benefit in prevention of DVT is extremely feeling well at the end of the flight, so it is about not limited and certainly what is significant about it, I drinking too much, it is about taking water and other would suggest, is that the side eVects outweigh any general well-being issues. Almost 100% of airlines in potential benefit. their in-flight magazines that you see on board the aircraft, there will be a piece about that including Q14 Lord Colwyn: Having taken aspirin for many, diagrams on how to exercise. There is usually a many years I was told at the meeting last week that in reference in the in-flight video if one is playing and on fact it only aVects arterial thrombosis, so for venous long haul flights there are often diVerent channels thrombosis it has no value at all. I am medical and I with in-flight entertainment and there is usually a did not know that, and I imagine that that channel to do with health or well-being and looking information probably does not get through to the after yourself. That information is being reviewed, as public. I mentioned earlier, following the inquiry into Dr Dowdall: If I can make a comment, My Lord perception of DVT and any references to the use of Chairman, one of the great advances we have seen is aspirin have been muted because one of the the gathering together of the international groups. conclusions of that research. The Department of One of the issues the Aviation Health Working Health then went on and investigated further that Group identified early on was the lack of consistency perhaps people were using aspirin far too often as of information to passengers, not just within the UK. some sort of way of ensuring they did not have a There have been huge strides made in trying to bring problem when they took a long journey, and that was groups together to use the same sort of information not thought medically to be necessarily an and to try and make sure that those sources of appropriate response, so we reviewed our inputs to information are accurate as far as they can be, where ensure that we were not encouraging people to take the evidence is good. As an example, the World aspirin because there are of course side eVects for Health Organisation has a publication on travel and some members of the public. health; the chapter on air travel and health was revised in 2004 with direct involvement from IATA— Q12 Lord Howie of Troon: Smoking has been its medical adviser and members of the Medical banned on quite a number of flights. If alcohol is Advisory Group. We recognise that inconsistency of harmful how would you think of banning it? information is a problem and we are doing our best Mr Wiltshire: Excessive alcohol certainly is an issue to address that, eg by using common sources of that the industry has to be aware of and it is known information whether it is at Department of Health that airlines will ban somebody travelling if it is level, the individual airlines or at World Health obvious that they are really worse for wear and they Organisation level. are going to cause a problem, and obviously there have been some incidents in flights that have been Q15 Lord Haskel: It is rightly believed that the linked to excessive drinking. Whether those incidents democratic profile and physical characteristics of the have actually been triggered originally by some flying public have changed. Passengers are getting frustration as that person is a smoker and cannot older, they are getting bigger, they are getting taller. smoke and decides to move to alcohol as an Do the airlines monitor or collect this data and, if alternative form of easing their journey is diYcult to so, how do they react to it? say. The industry would be concerned if it was Dr Popplestone: I do not think that the airlines attempting to ban too many activities by individuals. generally do collect data on that and they certainly Many, many travellers enjoy a modest alcohol intake do not collect the ages or the dates of birth of at the beginning of a long journey—it relaxes them it travelling passengers to have an awareness of what seems. They have been through quite a stressful the specific age profile would be on a flight. There experience quite often at the airport on departure and is anecdotal evidence—and I stress it is anecdotal— it is a way of relaxing, it is a way of feeling that they that would suggest that people with more complex can now deal with the journey in front of them and medical problems, for example, and more complex 3844421003 Page Type [E] 30-11-07 13:07:50 Pag Table: LOENEW PPSysB Unit: PAG1

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26 June 2007 Dr Nigel Dowdall, Dr Mark Popplestone and Mr Roger Wiltshire disabilities may be travelling, and that may be the Q17 Lord Howie of Troon: Do the manufacturers of case but the overall numbers of medical clearances, seats have this information, the demographic for example, that I see in Virgin and have seen information? If the airlines do not gather it do the previously at British Airways I do not think have people who design and manufacture seats gather this changed over time. In terms of the general information? physiological gathering of the size and shape of Mr Wiltshire: We would have diYculty answering individuals, no, we do not really have a mechanism that, you would have to ask seat manufacturers or to be able to collate that information. perhaps we could ask the seat manufacturers for you Dr Dowdall: If I can come in there we do have some and pass the answer back. I would imagine they indirect information in that we do obviously collect understand general body shape and size and have an a lot of information from passengers on their view understanding about whether they actually have of the travel experience, and clearly an important information suggesting a trend or a change in body factor in that and something that airlines compete dimensions. I do not know. quite strongly on is comfort—was your seat comfortable and is our seat more comfortable than Q18 Lord Howie of Troon: Do you buy a seat which our competitors. There is therefore some indirect an industrial designer has designed; that is really information drawn from that. Clearly, the same what I am saying? issue aVects all industries involved in transport, Dr Dowdall: Also, the passenger buys a seat and if the whether you are talking about trains, buses or passenger is not satisfied with the seat on the airline whatever, all have standard-sized seats and they are unlikely to fly with that airline again and will demographic change is something that we need to go and find somebody who they are more be aware of. At the moment there is not any 1 comfortable with. An interesting example of that is a indication that it is causing us a major problem, and couple of years ago American Airlines thought that certainly in terms of customer satisfaction the seats with the change in demographics it may well be are still positively rated. worthwhile reducing the number of seats and they took a couple of rows of seats out of their aircraft. They advertised it quite heavily but, in fact, Q16 Lord Haskel: What about the space between economically it did not stack up and they were forced the seats if people are getting a bit taller; are people to reverse the decision and put the seats back in able to adopt the brace position, for instance, which again, so price was a bigger driver in that market than we were told about last week? actually how much legroom you had and the extra Dr Dowdall: Most people can. Clearly there are inch or couple of inches did not make much extremes in terms of the size of the population and diVerence to the travelling public who, after all, we you may get some people who actually find that are trying to serve. diYcult; it is extremes at both ends, as very short people may have issues as well. That is one of the Q19 Lord Haskel: Irrespective of price do the benefits of the so-called “premium economy” that airlines feel that they have a duty of care, that they gives you a bit more legroom if actually that is what should at least provide enough space for people to you require. Another issue is to remember that pure adopt the brace position or that they should not be seat pitch does not actually give you an awful lot of physically uncomfortable during the flight. What information about how much space the individual about the low cost airlines, do they feel that they have passenger has got. Seat design comes into that as a duty of care to at least provide some sort of well and if we were purely to use seat pitch as a minimum conditions? measure of how much space the passenger has got, Mr Wiltshire: Yes, I think they do, as all airlines then I think that could be quite misleading. would feel they have a duty of care and they do 1 operate within the regulations. There is in this demographic data including age, gender, nationality and country of residence. We do not collect data on physical country a seat pitch regulation and it does not apply Fromcharacteristics, customer such surveys, as height British and weight. Airways We track collects satisfaction basic in other states—no other state in the world so far as with seat comfort and this data is fed into any seat improvement work. A few customers reference their height/size we know has a regulation that specifies what the as a factor in discomfort, but not enough to quantify minimum seat pitch should be, and all airlines as far eVectively. We have very few complaints about seat comfort–it as I know operating in the UK operate above that tends to be a driver of satisfaction/dissatisfaction, not complaints. Seating complaints tend to be about not getting minimum seat distance, whether it be on short haul or pre-allocated seating requests, etc. We use specialist ergonomic long haul. agencies to assist us with seat trials, to ensure we understand the comfort, safety, etc, implications of diVerent seat widths and pitches. The agencies recruit people of all shapes and sizes to ensure that their findings are representative of the passenger Q20 Lord Haskel: There is a minimum and that is population. where duty of care lies. 3844421003 Page Type [O] 30-11-07 13:07:50 Pag Table: LOENEW PPSysB Unit: PAG1

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26 June 2007 Dr Nigel Dowdall, Dr Mark Popplestone and Mr Roger Wiltshire

Dr Dowdall: Yes, there is a minimum stipulated by Dr Popplestone: From the Virgin Atlantic perspective the CAA and of course that responsibility is being I would echo everything that Dr Dowdall has said. taken over by the European aviation safety There is a lot more information available on the BA organisation at the moment. That process has started website, the Virgin Atlantic website, and many other already but we will have to see what that European airlines’ websites, on fitness to fly. As far as our staV organisation, EASA, decides to do about seat pitch are concerned, we put all our ground staV through a regulations and whether it wishes to apply that as a training programme to give them a basic idea of the pan-European regulation. sort of thing they are looking for in terms of identifying sick passengers, either at check-in or at the gates when they go to board the aircraft, and then Q21 Chairman: Does that include airlines that land there is a system in place that if they have any cause in Britain? for concern they can talk to the passenger and they Mr Wiltshire: At the moment, no, the CAA can get expert advice from the MedLink service, regulation applies to UK-registered airlines only, but which will make an assessment on the spot with the as far as I know the industry operates to very similar information available, do they think they are fit to fly, seat pitch standards. Otherwise, as Nigel said, there and if they are not they will say that you should refuse would be a competitive reaction from passengers immediately if they felt that they were getting a better carriage to the passenger until more information is deal on comfort versus price with one airline versus available. another, so airlines operate to a very similar standard worldwide. Q24 Lord Colwyn: Is this information also available pre-booking as well as post-booking? Q22 Lord Colwyn: We had a brief discussion about Dr Popplestone: Yes, and if you, for example, go to alcohol during the first question. Can you tell me, book a ticket through the Virgin Atlantic website, as have the airlines’ systems for ensuring that you get onto the second page (or it might be on the passengers are fit to fly changed in any way since first page as you go through the process) there is a 2000? I fly fairly regularly and I am not aware of any link that says if you have any concerns over either change that I have noticed and I wondered whether additional needs or disabilities, or if you have any oYcially there is any change? medical problems, there is more information here Dr Dowdall: I can only speak for British Airways and and you can contact the special assistance unit of prior to the inquiry we already had in place systems. Virgin Atlantic where you will talk to trained staV, We have a passenger medical clearance unit which they will get information from you, they will arrange provides advice to passengers and their medical to get information from your doctor and either the advisers on fitness to fly and that contact information staV there will make an assessment on fitness to fly or is on our website. We also have a service through they will pass it on to a medical expert who will. MedLink, which is a ground-to-air medical advisory service, and they also provide what we call “gate clearance”; if any of our ground staV or cabin crew Q25 Lord Colwyn: Has there been any change in the when passengers are boarding are concerned about a check-in facilities at the gate and are the staV there passenger’s fitness to fly, then they can contact given special training and time to identify people who MedLink for advice. We do therefore have systems are not well enough for either providing advice to passengers who have Dr Popplestone: For Virgin Atlantic they are, that is concerns about their fitness to fly or for identifying something that has happened over the last few years. and asking questions about passengers who appear We look at the information that we get from in-flight as if they may not be fit to fly. medical emergencies, and one of the things we are conscious of is that if you have an illness before you get on board an aircraft you are perhaps more likely Q23 Lord Colwyn: Are passengers observed by to have a problem once you are on board, and so anyone other than the check-in desks? what we have done is we have given some awareness Dr Dowdall: No, they are not and it is important to training to the ground staV, we have given them a remember that we fly over 30 million passengers a manual, things to look out for, in order to try and year and have very few in-flight medical problems, so identify people before they board. the systems that we have in place actually work quite well. It is not in our interests to allow people to board who patently are not fit to fly because that is going to Q26 Lord Colwyn: I dealt with an emergency two or create us problems, either with diversions or three years ago where someone was in a managing the situation in-flight, so we are as keen as hypoglycaemic coma. I do not understand how that anyone else to avoid in-flight problems and the could happen, but the plane had been delayed, and I system works as eVectively as it reasonably can. imagine that the passenger had missed a meal. 3844421003 Page Type [E] 30-11-07 13:07:50 Pag Table: LOENEW PPSysB Unit: PAG1

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26 June 2007 Dr Nigel Dowdall, Dr Mark Popplestone and Mr Roger Wiltshire

Dr Popplestone: It happens in normal life, these things unwell, some people with pre-existing medical do happen, and as airlines we want to carry conditions. passengers. Passengers who either have long term illnesses such as diabetes or short term illnesses still Q31 Chairman: I am trying to sense whether this is a want to fly, so what we do is we do our best to enable problem or not; you are indicating that it probably is people who are fit enough to fly to fly, but sometimes not a problem. if a meal is delayed, if they have been hurrying Dr Dowdall: We want that number to be as small as through the airport, if they have had a drink of possible; we have probably gone as far as we alcohol or something, it may tip them over the realistically can in terms of stopping people flying balance into something like hypoglycaemia, but there who should not. are then facilities on board—there are medications Dr Popplestone: If I could just add to that, I previously for the staV, for the crew to use and also for travelling worked for British Airways and analysed two years’ medical professionals to use to actually get the worth of medical diversions, because that was a passenger through that emergency. manageable number of cases to look at, and it was something over 100 cases, 88 of which we had fairly Q27 Lord Colwyn: Do you have any instances where detailed medical information on. Of those I recall oV passengers refuse to answer questions relating to the top of my head that something like 11 of them their relevant health when questioned at check-in or had, as it transpired, what one might call significant at the gate, or even if they look unwell? medical problems before they got on the aircraft and Dr Popplestone: I do not have any specific data, but I that the airline was not aware of, so that was 11 out am sure it does happen. If the staV have doubt about of 88. The only other factor that one could identify somebody’s fitness to fly then they can refuse to before they got on board that might give an carry them. indication that somebody was more likely to cause a medical diversion was actually age, so there was a Q28 Lord Colwyn: For someone checking-in it could peak in the over 50s but beyond that there was well be a couple of hours before they board the plane nothing else that you could identify as possibly being and so lots of things could happen. a likely factor in medical diversion. Clearly, Dr Popplestone: But as you get to the boarding gate identifying those 11 would be ideal, but it is very there are then more staV who again look at you, they diYcult to do if the passenger is not going to take your boarding card and they check you in as you disclose it. go through to the flight and then you have the crew on board the aircraft as well as the final sort of Q32 Earl of Selborne: Do the airlines ever run into backstop as it were, but once the person has got there problems when they determine not to carry a and they have been through the airport environment, passenger because of reasons of ill-health or sometimes the long distance through the airport will infection? Do you have suYcient powers simply to be enough in some individuals to exacerbate a say you are not prepared to take them? medical problem. People do get through that process Dr Popplestone: I have looked at British Airways unnoticed. terms and conditions of carriage and it actually says “Our right to refuse to carry you if your mental or Q29 Lord Colwyn: It is not really a problem as far as physical state or health is a danger or risk to you, the you are concerned. aircraft or any person in it.” So under their terms and Dr Dowdall: I do not think it is an issue we could conditions of carriage one can refuse to carry them realistically do much more about; we have as many and ultimately it is the captain of the aircraft who can checks and balances in as we reasonably can. make a decision on that.

Q30 Chairman: Your evidence from British Airways Q33 Earl of Selborne: Do you ever find yourself in said that you had something like 1,700 medical court or challenged on this? incidents in the air; it should be possible to analyse Mr Wiltshire: I have seen some cases of passengers those and see which cases might have been avoided who have been oZoaded because of a medical with better filtering. problem, demanding that they should not have been Dr Dowdall: That is 1,700 where the crew sought the oZoaded, that they have recovered ten minutes later advice of the MedLink ground-to-air medical and should have been allowed to travel. I have seen advisory service. There are a range of conditions, examples of complaint cases asking for most of them trivial, and there will be a small number compensation. of serious illnesses, some of which will lead to diversions, but in the context of 30 million plus Q34 Earl of Selborne: Do you keep records of the passengers and a number of quite long flights, it is number of passengers that you are not prepared to inevitable that actually some people will become carry? 3844421003 Page Type [O] 30-11-07 13:07:50 Pag Table: LOENEW PPSysB Unit: PAG1

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26 June 2007 Dr Nigel Dowdall, Dr Mark Popplestone and Mr Roger Wiltshire

Dr Popplestone: We have some figures and I suppose board on it. Certainly that is one of the many benefits they fall into two categories, those who identify of taking out medical insurance before you travel. themselves with medical problems well before the flight, and when you have been through the medical Q38 Baroness Perry of Southwark: I do have a rather information on that out of the thousands who come colourful memory of sitting in the lounge close to a forward for what I would call medical screening, it passenger who was being told that the airline was really is a handful that are declined. I know the refusing to fly him because he had had rather too British Airways figures when I was there, it was much to drink, and he was quite vocal about his something in the region of 7,500 cases who were aZictions. My question, however, is do you think assessed by the passenger clearance unit, or who were there is a case for standardised guidelines for carrying assessed by them, and only about 40 were refused ill passengers across all the airlines? Should there be travel in the course of a year and they fell into three a standard rule rather than people saying one airline main categories: those who were terminally ill who is softer than another, and if you do think it would be we felt were unlikely to make the flight, those who a good idea who would do it, what agency would be were so seriously ill, intensive care-type patients, that responsible for that? again it was impractical for travel, and the third were Dr Dowdall: We all have a common interest in people with acute psychiatric illnesses who, again, it avoiding carrying people who should not be carried, would be inappropriate to carry on board. The and again it is one of the benefits of the much greater figures for Virgin Atlantic show that we decline a interest in air travel and health that we are seeing at handful a year. When you get to the gate screening an international level. There are guidelines being where people are identified just prior to travel, the agreed and so, for instance, the Aerospace Medical percentage of people that you turn down—again, I Association, which is probably the largest aviation was looking for some industry figures yesterday medicine organisation, publishes on its website provided by MedLink and something like between 15 guidelines both for passengers and for doctors, and 20% of passengers who are identified at the gate guidelines on air travel and health. are refused to travel at that point, but that does not mean to say they do not travel subsequently when Q39 Baroness Perry of Southwark: Do the airlines more information is available. The reason for the follow that, is that accepted by all airlines? higher percentage, I firmly believe, is simply because Dr Dowdall: I would not say accepted by all airlines, of lack of information. but those common sources of information are what we are drawing people to refer to. For instance, Q35 Lord Colwyn: If you have a family who have IATA (International Air Transport Association) in had a holiday booked for six months and on the its advice links in with the work that is going on in the morning of flight the youngest goes down with a Aerospace Medical Association. Fortunately, the chicken pox rash, or measles, you are unlikely to be speciality is fairly small so those of us who are told about it, surely. involved in it tend to know each other so there is good Dr Dowdall: Funnily enough, chicken pox is one of communication and we share information, leading to those ones that is easiest to spot because the spots increasing consistency in information generally. The come out on the face. It is very unfortunate if you information is about what eVect does air travel have have planned your holiday and your child— on your health and what eVect does your health have on your fitness to travel by air. Q36 Lord Colwyn: You are unlikely to be told because they want to go on their holiday. Q40 Baroness Perry of Southwark: When you say Dr Dowdall: If you went on the website and looked that you are a small group and you all know each then the information would be there, but I accept that other, does that include the low-cost airlines? that is a situation where people are quite likely not to Dr Dowdall: It is not just airlines but those people think it is going to be a problem, will arrive at the who are interested in aviation medicine. Not every airport and will be refused travel at that point and, airline has a fulltime or indeed any medical adviser— regrettably, we would refuse travel if one of the and I am talking globally here, not necessarily within children had chicken pox and was contagious or the UK. Those of us who are working in the area do potentially contagious. tend to know each other because we meet at the same international meetings. Q37 Lord Colwyn: With some airlines you would not get a refund, would you? Q41 Baroness Finlay of LlandaV: I wonder if you Dr Popplestone: One would hope that the family could tell us actually to what extent the airlines would have travel insurance and it would be covered overall collect data on in-flight medical emergencies by that. In general airlines are fairly sympathetic to and whether this data is pooled and what is done medical issues but I could not give policy across the with it? 3844421003 Page Type [E] 30-11-07 13:07:50 Pag Table: LOENEW PPSysB Unit: PAG1

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26 June 2007 Dr Nigel Dowdall, Dr Mark Popplestone and Mr Roger Wiltshire

Dr Popplestone: That is quite a complex question. We incident and we get a report back later on from are talking about in-flight medical incidents are we? MedLink and we can then marry them up and learn from that data. Q42 Baroness Finlay of LlandaV: Yes, in-flight medical emergencies. Q44 Baroness Finlay of LlandaV: With diversions Dr Popplestone: Most airlines now use a remote does the qualification of the person who does the in- medical adviser, ground-to-air medical advice, and flight assessment influence the number of decisions the biggest provider—it is not the only provider—is taken to divert? a company called MedAire, based in Phoenix, which Dr Popplestone: I do not know that there is an easy provides a service called MedLink. MedLink will answer to that because there are so many factors collate data individually for the airline, which is fed involved in a medical diversion, one of which is quite back to that airline specifically, and it will also rightly the medical condition of the passenger and, provide information back to every airline on the clearly, if you have a medically qualified volunteer industry data, so it gives an industry-wide picture as with that individual you might be more confident in well so that I in Virgin can compare my figures to the what the diagnosis is. Just because you may have industry as a whole—all subscribers to the MedLink somebody in front of you with a heart attack, it does service. There are a couple of big diYculties with not necessarily mean you would divert as soon as analysing the data, particularly on the medical possible because it really does depend on where you information and medical diagnosis, and that is that would be diverting to and what the facilities would the category that MedLink assign to a particular case be. is based on information provided by a lay person in any respect, so if somebody has, for example, abdominal pain, it may go into a gastrointestinal Q45 Baroness Finlay of LlandaV: What I was getting category, it might go into a gynaecological category at is whether the risk assessment process correlates or it might even go into a cardiac category, depending with the qualification of the person, so whether you on its nature, so it can be very diYcult to analyse find that one group of people such as nurses or consistently what that information means and then pharmacists may be more risk averse than senior act on it afterwards. Certainly, speaking for Virgin clinicians who have got quite a lot of experience Atlantic, in respect of the major incidents—the behind them and may feel “we can carry on and I can diversions or anything like that—we do get as much manage this, the chances of it getting any worse are information as we can possibly get back from much lower”? MedLink, analyse that data and then try and learn Dr Popplestone: I do not think I have any evidence to from it and see what we can do better in the future. say anything on that. Dr Dowdall: The only thing I would say on that is remembering British Airways’ experience in the time Q43 Baroness Finlay of LlandaV: What about before we took on the MedLink service and we were incidents where MedLink is not involved and where seeing a rising trend in diversions. We then switched you might have a doctor or a nurse on the plane who to the MedLink service and what we saw was a fall in is the person who responds to a call? Is that data diversions. We did a comparison of diversions where collected anywhere or is it lost? MedLink had been involved and diversions where an Dr Popplestone: Again, speaking for Virgin Atlantic, on-board physician had been involved and what the we train all our crew—our crews when they arrive at outcome was on the ground; we found that the the airline get five days of extensive medical training MedLink-advised diversions were much more likely and they then get a refresher on an annual basis. The to result in a significant medical condition being protocol that they follow is that in the event of a identified on the ground. You might well have a medical emergency—for minor incidents such as if physician on board but they are out of their normal somebody has a headache they might just give them sphere of activity, they do not have their normal two paracetomol—or anything where they need equipment— advice or it is more complex, their training is that their first port of call should be to contact MedLink, and there is virtually nowhere in the world that you Q46 Baroness Finlay of LlandaV: And their cannot contact them because you contact them by specialty. satellite phone. If the advisers at MedLink, who are Dr Dowdall: They may well be from the wrong doctors, believe that it would be helpful to get a specialty, it is a very uncomfortable and diYcult hands-on medical assessment, at that point a call will situation for them. What we have found is that in a go out for a medical volunteer. I will pass on to Dr situation where you have contacted MedLink and Dowdall in a moment and he can describe what they would like a further assessment, if you then have happens when you cannot get hold of MedLink, but an on-board physician working with MedLink that is that is the protocol. The crew fill in a form after the often a very eVective combination. We do not use it 3844421003 Page Type [O] 30-11-07 13:07:50 Pag Table: LOENEW PPSysB Unit: PAG1

air travel and health: evidence 15

26 June 2007 Dr Nigel Dowdall, Dr Mark Popplestone and Mr Roger Wiltshire very often, we are talking about tens of flights out of Dr Dowdall: You talked about perception and the hundreds of thousands flights. myth that we see is that recirculated air causes problems and increases the risk of transmission of Q47 Baroness Finlay of LlandaV: Is there a infection. The evidence is very clear that following discernible pattern to these medical emergencies and recirculation, which is through the HEPA filters that does that pattern correlate with pre-existing we discussed earlier, the microbial content and the conditions now these data have been collated? quality of the air is very good and that recirculation Dr Dowdall: If you looked at the biggest single cause is not a factor in the transmission of disease. Clearly, of diversions for most airlines it is probably chest in an aircraft you are in a confined environment, you pains, and that is simply because it is the one where it are sat close to other people and as in any other case is hardest to be sure what is the underlying problem where you are in a situation where you are sat close and the consequences of making the wrong decision to other people, there is the potential for the direct are perhaps more significant, so we are more likely to spread of infection, usually by the droplet method, so divert for a chest pain; 50% or more will turn out to somebody coughs, there is a spray of germs and if you be trivial chest pain that did not indicate a serious are in the path of that cough then you are exposed to medical condition. it. In air travel, the air quality is good but you cannot control who you are sat next to although clearly we try to avoid boarding people who look unwell, so we Q48 Baroness Finlay of LlandaV: How much do try and minimise that. You mentioned SARS and chest pain diversions cost your airline in a year; do what is evident is that air travel moves people around you have any idea? the world very quickly; if you have somebody who is Dr Popplestone: I could not answer that, I do not well, has no symptoms or minimal symptoms, is think it is possible to quantify how much it costs. Just perhaps incubating an illness, they can get on board to put the chest pain thing into perspective, less than when they are well, they can get oV when they are still 5% of the in-flight incidents according to BA figures a well and 24 hours later is when they develop couple of years ago were thought to be due to cardiac symptoms. That is something that we cannot prevent problems yet they accounted for more than 20% of and talking about pandemic flu, the current major diversions. It is the same from a neurological point of concern, if you were to stop air travel the belief is that view, which of course will include headaches and it would delay the spread of a pandemic— things, 20% fall into that category, and will also include faints, but they accounted for over 35% of the diversions, so there is a disproportionate thing with Q50 Lord Patel: It would stop anyway because you neurological and cardiac problems. We do not know would have no crew. how much they cost, there are so many diVerent Dr Dowdall: The concern actually from the airline factors involved and it is not a factor that is taken point of is will we have any passengers. If you were to into consideration when it comes to diverting. stop air travel you would delay the spread of a Dr Dowdall: A diversion can be what is called a “fuel pandemic from an origin in Asia to the UK by, at and go” which is literally you land, oZoad the best, a few weeks. Air travel does take people from passenger, put in some extra fuel and go, and that one part of the world to another part of the world costs you essentially a bit of extra fuel and a landing very quickly; if they are unwell before they board charge, to the one where you land, the crew go out of then you can stop them, if they become unwell on duty time and you have to put everybody in hotels, so board then we have protocols for how we deal with it, you are talking from a couple of thousand to if they get on appearing well and get oV appearing hundreds of thousands in terms of the range of costs. well there is nothing we can do about it.

Q49 Lord Patel: The general perception that the Q51 Lord Patel: If I heard you clearly you save a few airline cabin environment is such, particularly the air weeks; therefore if pandemic flu occurred in south- circulation, that it is more conducive to the transfer east Asia it would delay it by a few weeks by not of particular infectious diseases and therefore airlines transferring people from there to here; that is quite ought to have some precautionary measures in significant. place—first of all what are the regulations relating to Dr Dowdall: Clearly if you were to stop air travel control of diseases? The Department of Health completely then that would have a substantial currently is consulting on the Control of Diseases economic eVect on a global scale and is something 1984 Act because of the WHO international that governments quite rightly would be very guidelines that came out; are the airlines responding reluctant to do. There would be little benefit to the to that and what do you learn from previous episodes public health, I would suggest, if you were to do that. such as SARS in terms of control of infectious diseases in the air cabin environment or the recent Q52 Lord Patel: We will not get into it, but it might resistant tuberculosis? save a lot of lives. 3844421003 Page Type [E] 30-11-07 13:07:50 Pag Table: LOENEW PPSysB Unit: PAG1

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26 June 2007 Dr Nigel Dowdall, Dr Mark Popplestone and Mr Roger Wiltshire

Dr Dowdall: But we are not talking about stopping Q57 Lord Patel: When I read the newspaper as a the spread of a pandemic, we are talking about member of the public I am not going to think that. delaying it in that scenario. Dr Dowdall: I agree and one of the things I would like to point out is that the 2000 report highlighted the Q53 Lord Patel: Let me come back to my original role of the media in responsible publicity, and we question which was are you consulting on the have seen signs that they still have not taken that on Department of Health consultation on the spread of board. In terms of that situation, if you have travelled diseases and does this have any implications for the on board a flight where somebody with contagious airlines? TB has been identified—and usually they are Dr Dowdall: In terms of the new international health identified some time after travel—then the public regulations the international airline industry has had health authority that is managing the case would some input into the discussions with WHO and contact the airline and say “We believe this person ICAO. travelled on a flight.” We would check our records to see if that person did travel on that flight, and the Q54 Lord Patel: What has been your input? How standard information we would be looking for is would you like to see the regulations change? those passengers believed to be potentially at risk Dr Dowdall: It is not a case of how I would like to see would be those people who were sat in the same row the regulations change. What is proposed in the and the two rows either side—that is the standard. international health regulations, which is to be We would look to provide the public health implemented in the UK, is perfectly sensible and I am authorities with whatever contact information we very comfortable with those regulations being had available so that the public authorities could implemented as they are. It is a step forward in terms contact those individuals, explaining what the risk is of international travel and health. and what they should do about it. Dr Popplestone: I would echo everything that Dr Dowdall has said and the only thing I would add to Q58 Lord Patel: Even in a case of such a serious that is that we communicate with the public health contagious disease as resistant TB it would only be bodies and the Health Protection Agency, we work two rows of passengers either side who would be with them and, ultimately, anything that is brought informed. into place we want to see work. We want to be Dr Dowdall: Because the risk is very, very small and practical but we work with them to try and make sure worldwide there have only been eight documented that what is being implemented in the airports on the cases where TB actually has been transmitted from a ground is actually compatible with what we do and is passenger on an aircraft to another passenger. TB is practical. not that easy to catch and so, for example, there have been no cases where the duration of travel was less Q55 Lord Patel: What happens in a situation like the than— case recently about resistant tuberculosis and therefore there was a risk to other passengers. Is there Q59 Lord Patel: But generally any infectious disease any follow-up or is there any advice given to the other would be two rows? passengers who were in that aeroplane? Dr Dowdall: Yes, and that is based on droplet spread, Dr Dowdall: That is a matter that the public health so if you cough how far do you spread bugs basically. authorities would lead on. Again, I was involved in That is the risk assessment, that is where the evidence the reworking of the WHO booklet on air travel and says this is where it is worthwhile doing the contact tuberculosis and there were very clear tracing. recommendations on first of all what the treating Dr Popplestone: The only thing I was going to add physician should do, what their responsibilities are, goes back to the responsible journalism point. The what the airline’s responsibilities are and what the recently highlighted case of the multi-drug-resistant public health responsibilities are. We frequently co- TB, there are a number of factors that are in the operate with the public health authorities. guidelines as to whether or not you should do contact tracing, one of which is whether or not the person had Q56 Lord Patel: If I was a passenger on an aeroplane bacteria in their sputum at the time. This person did and it subsequently was found out that someone was not have it and he was not coughing at the time of carrying at the same time as the flight I was on travel either, so although he had multi-drug-resistant resistant tuberculosis, an infective passenger, how TB, there was absolutely no evidence that he was would I know? Who would contact me to say that I contagious and ironically, I believe, had been told need to be screened or whatever? that he could fly by a relative who worked for the Dr Dowdall: First of all it is important to emphasise CDC in the States. Although he had multi-drug- that the risk is very low and of the studies that have resistant TB, I do not think there was any evidence at been done of transmission of tuberculosis— all that he was infectious at the time of travel. Clearly 3844421003 Page Type [O] 30-11-07 13:07:50 Pag Table: LOENEW PPSysB Unit: PAG1

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26 June 2007 Dr Nigel Dowdall, Dr Mark Popplestone and Mr Roger Wiltshire it was undesirable that he flew, but there was not someone who has symptoms, so they maybe have a actually any risk, I do not believe, to any other fever and a cough, and there are guidelines and passenger. procedures for how you manage that, how you alert the public health authorities on the ground. So there Q60 Lord Haskel: Coming to the matter of a are some procedures that are in place all the time and pandemic of influenza, are there any contingency then from the airline point of view we would make plans to deal with an outbreak? If you know that an specific plans in relation to a possible pandemic. outbreak has occurred do you have contingency plans to deal with it so that there is a routine which Q63 Earl of Selborne: When airlines are procuring just goes into operation? and commissioning aircraft, do the chief medical Dr Dowdall: Any airline that does not have oYcers of the airlines get to make a contribution on contingency plans is somewhat remiss for its cabin configuration or seats and such like? shareholders, because for us it is a business continuity Dr Popplestone: I was due to be meeting our head of issue. In terms of what we should all be doing, design today, but I am here instead. There are a lot of International Civil Aviation Organisation, factors that are involved in new aircraft design, new International Air Transport Association and the seat design, new cabin design which will involve WHO had a meeting a couple of years ago in weight, comfort, general company ethos and Singapore where they developed protocols and whatever. Up until recently Virgin did not have a guidance for airlines, for airports, and those are dedicated chief medical oYcer or head of medical published and made available. Certainly most of the services but they did through very informal major airlines have taken that on board and have arrangements get involved with the design team. developed their plans and are clearly working in With the arrival of me in the organisation, it is now conjunction with their other business partners, something that we are looking at building on, to try government agencies and so on. It is certainly to make sure there is a medical contribution to the happening in the UK, where the CAA Aviation design process. The driver in putting in any sorts of Health Unit is the focal point for the liaison between seats onboard an aircraft, goes back to what Dr airlines and airports and the Department of Health, Dowdall was saying earlier on, that it is comfort, and the Department of Transport, etc, in pandemic airlines compete quite fiercely on comfort. In general planning. terms, if it is going to be comfortable, then there are not going to be many adverse implications to deal Q61 Lord Haskel: Have these plans been tested? Do with. One has to be careful that you do not put some we know that they work? sort of design amendment in that you believe may Dr Dowdall: There have been a number of exercises. reduce the incidence of DVT but which may have an The Government has run exercises. My own airline is unintended consequence of not achieving that. planning on exercising our plan later this year. Certainly we do try to work with the design team to Dr Popplestone: Virgin Atlantic took part in a recent make sure there is a medical aspect to it. exercise run by the Department of Health and, yes, we run regular contingency planning exercises. We have a working group within the airline. You gain Q64 Earl of Selborne: Would you be able to make a information on contingency planning because it is a contribution, for example, in the seat chosen by the business threatening problem. But in everything we airline? Some are clearly going to have more do we try to work with the Department of Health, to medically adverse pressure points than others. work with the Government Health Protection Would that be a view that you would be able to take? Agency. The other complicating factor, of course, is Dr Dowdall: We could certainly contribute to that, that we have to interact with the public health yes. Absolutely. It would take all factors. As I said, it authorities of many diVerent countries around the is one of the many aspects of designing a seat or a world as well, but we do what we can to try to make cabin. Yes, if we felt something was going to be sure that all things are compatible with that. detrimental to an individual’s health, then we would certainly have the opportunity to say it and I believe within my organisation it would be taken on board. Q62 Lord Haskel: The staV play a part in this. They know how to deal with the passengers. Dr Dowdall: In terms of passengers, pandemic flu is Q65 Earl of Selborne: Is there any evidence which no diVerent from any other contagious disease, so, shows that one airline seat is better than another in yes, part of our training is for staV. Again, IATA has terms of pressure points? produced guidelines applicable to cabin crew, to Dr Popplestone: There is industry-wide data that ground staV and, indeed, to cleaning staV for how compares passenger comfort and passenger you manage an incidence of suspected communicable satisfaction with, dare I say, Virgin’s economy cabin, disease. Of course, on board the aircraft, you just get British Airways, American Airlines. The airlines can 3844421003 Page Type [E] 30-11-07 13:07:50 Pag Table: LOENEW PPSysB Unit: PAG1

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26 June 2007 Dr Nigel Dowdall, Dr Mark Popplestone and Mr Roger Wiltshire compare with each other to see how they are seen Q68 Lord Howie of Troon: For how long have you compared with competitors. been in this business, then? Mr Wiltshire: Of course when an airline introduces a Dr Dowdall: I have been in aviation medicine for 30- new cabin configuration, it often tests that out with odd years. I have been with British Airways for 11 passengers or with travellers and asks them to trial years. I am sorry, are you talking about the business the seat. The seat manufactures do the same thing. class seat. These are not products that have suddenly appeared on an aircraft without being assessed in terms of their Q69 Lord Howie of Troon: Yes, where you climb perceptions of comfort, their real comfort and other over each other. factors as well. Airlines obviously have a great Dr Dowdall: I think it is commercial trade-oVs. Our interest in satisfying what their consumers want and new configuration aims to reduce the number of seats obviously seat comfort is one of those aspects. where people do have to step over. Dr Dowdall: I think it is important to recognise that in terms of seat design health is almost an irrelevant Q70 Lord Howie of Troon: I think of Lady Thatcher. issue, in that seat comfort is not an objective measure, She would put her handkerchief over. it is subjective: there are many diVerent body shapes Dr Dowdall: I think, from a customer satisfaction and, as you know, with any seat design some people point of view, our business class cabin is very highly will find one seat comfortable and not another, for regarded. somebody else, it is the other way around. I do not think, in terms of health contribution, there is or Q71 Baroness Finlay of LlandaV: Is there any data should be a major input these days from an airline on a lower number of medical emergencies, medical department. I think we can have a role, and particularly DVTs, from flatbed seats versus seats an example I would give would be when British which maintain an incline all the way through the Airways introduced the rearward facing seats in flight? business class. There were concerns about how that Dr Dowdall: We do not have any data on in-flight would aVect people’s physiology and how people DVT because it is impossible to diagnose. would react to that and what we needed to do about the “brace position”, as there is a diVerent position Q72 Baroness Finlay of LlandaV: I was thinking facing backwards from when you are facing about medical emergencies which occur. I wondered forwards. Then, yes, our department was involved, if you had collected that data. because those were issues where it was felt that our Dr Popplestone: I do not think that is broken down. knowledge of aviation medicine could make a We do not get that data. contribution. Dr Dowdall: The numbers would be so small that it would be very diYcult to draw any significant Q66 Lord Howie of Troon: With regard to this long- conclusions from them. haul configuration, what consideration was given to Baroness Finlay of LlandaV: I would have expected a the problem of someone in an inside seat stepping health benefit, but there we are. over someone in an aisle seat to get to wherever they wanted to go? Q73 Chairman: At the time of the original inquiry, Dr Dowdall: From a health perspective, other than most of the anecdotal evidence received was from the fact that people can get fairly irritated if they keep members of the public with regard to DVT. This time getting kicked, I do not think it is a health issue. It is around half of the anecdotal evidence we have about what is commercially viable, what will received is from pilots and cabin crew concerning passengers accept, what will make them choose one fume events inside aircraft and, in particular, in the airline over the other? If you were to give people the cockpit. What action are the airlines taking to meet choice between sitting in a leading-side seat or sitting concerns expressed by pilots, unions and others on in a seat that had much more leg room, they clearly this issue? would choose a lot more space, but economic factors Mr Wiltshire: There have been some fume events on come into it, so I think if you said: “Is the three- certain aircraft historically. These events have all abreast reasonable in terms of the space?” then yes. been investigated by the airlines and by the regulator, and, where appropriate, technical modifications have Q67 Lord Howie of Troon: This configuration was been made if a technical issue has been discovered. presumably tested with real people climbing over We have no evidence to suggest that there is a serious each other. What sort of reaction came back from medical problem here but we are very much involved them about that specific detail? through the Aviation Health Working Group and Dr Dowdall: I know those seat configurations have the research that will now be taken forward by the been around for far longer than I have been in the Department of Health, COT, and the sampling of air industry. I do not know if Roger can comment. in aircraft. We will continue to assist the authorities, 3844421003 Page Type [O] 30-11-07 13:07:50 Pag Table: LOENEW PPSysB Unit: PAG1

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26 June 2007 Dr Nigel Dowdall, Dr Mark Popplestone and Mr Roger Wiltshire the regulator and the Government with that to see if increasing. In fact, they tend to have reduced a bit there is a problem here. The industry does not see any recently. trend or a particular issue here as far as health is concerned but we are working closely with those who Q76 Chairman: Will you or have you made the data are doing further research. that you hold on aircrew health available to assist in Dr Dowdall: From a BA perspective, safety is our the AHWG-sponsored research into the health number one priority. We have always taken fume impacts of toxic air? events seriously. If reported, these events are always Dr Dowdall: I am not sure what you mean by investigated. The concerns about health are relatively information we hold on aircrew health. new, from a relatively small number of individuals. We have looked at the evidence. From the evidence that is currently available, I do not see anything Q77 Chairman: We are aware that a number of convincing that there is either a significant short-term pilots have complained. Some evidence we have or long-term impact on health, but, having said that, heard has suggested there have been 27 cases or we also recognise that the evidence is incomplete. something of that order, so you must have received One of the particular diYculties we have had is that, these complaints or concerns and the question is although we can sample cabin air during normal whether you have reported the data you have on operation, events of contamination are infrequent those concerns to the group. and unpredictable and there has not been the Dr Dowdall: For confidentiality reasons, we clearly opportunity, the suitable equipment, to capture an cannot talk about individual pilot’s medical event and analyse exactly what it is the crew may be conditions. We do not have any evidence that links exposed to. I do not have any evidence that there is a fume events to illness. In that respect, we have not health problem, but we are interested and supporting because we do not actually have any evidence. We are the work of the Aviation Health Working Group in aware of particular individuals who believe that their investigating the concerns and we are actively health has been aVected but belief and reality . . . We investigating the concerns. As Roger said, there is do not say there is not a link; we just say we do not ongoing work to look at that. have evidence that suggests that there definitely is a link. We are keen to continue with the work and the research. The Committee on Toxicity (COT) are Q74 Chairman: It has even been suggested that fume looking at all the available evidence and there is a events are grossly underreported because pilots fear whole raft of information that is available. We for their jobs. Do the airlines keep records of fume provide all the information we have, the aircraft events? You have mentioned that but can you be manufactures, the engine manufactures, the oil confident of the integrity of the figures? companies, have all cooperated in providing Dr Dowdall: With any reporting system you will information and evidence to the Committee on never get 100% reporting. I think we can be very Toxicity in their review of the evidence and, as Roger confident that the more serious events will be said, we are working with the Aviation Health reported. As they get more and more minor, Working Group on trying to put in place some individual pilots will have a threshold both for research that will answer some of the questions where detecting smells and for reporting them. I am very we do not have the evidence. clear that in British Airways we have a very open reporting culture: we encourage reporting and we take those reports serious and they are followed up Q78 Lord Patel: Are the fume incidents easy to and investigated. identify? Dr Dowdall: There is a percentage of incidents where, yes, you find an underlying fault and you are able to Q75 Chairman: Have there been cases where there correct it. have been fumes in the passenger compartments and the public has complained? Dr Dowdall: I have spoken to our customer service Q79 Lord Patel: If you are in the cabin of an aircraft, people and it is not an issue that customers report or are fume incidents easy to identify? complain to us. Dr Dowdall: The human nose is very sensitive and Mr Wiltshire: There have been one or two specific most of these incidents involve volatile organic incidents, several years ago, of aircraft where smoke components. Yes, people are able to detect very low appeared in both the cabin and the cockpit. Those levels of compounds. events, as I said earlier, were fully investigated. They become incidents that are fully investigated by the Q80 Lord Patel: What is the main constituent of authorities and any technical issues resolved. But these fumes chemically that would cause harm? these events were very small in number and there has Dr Dowdall: We do not know because we have not been, as far as I understand, no trend of those events been able to test for it. 3844421003 Page Type [E] 30-11-07 13:07:50 Pag Table: LOENEW PPSysB Unit: PAG1

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26 June 2007 Dr Nigel Dowdall, Dr Mark Popplestone and Mr Roger Wiltshire

Q81 Lord Patel: What are you monitoring? You said Q86 Lord Patel: There seems to be disagreement earlier on you are sampling when there is a amongst you whether it is easy to identify a fume likelihood. What are you sampling for? event or not. Dr Dowdall: We have done research programmes in Dr Dowdall: In the research context, the programme the past where we have measured cabin air in normal is being set up specifically to try to maximise the operation. opportunity of capturing a fume event in a research programme. I am saying that you could not routinely, on every British Airways flight, have Q82 Lord Patel: For what? equipment on board just in case you had an event. Dr Dowdall: For a whole range of things, but You can do it in research context and that is what we including volatile organic compounds and a whole are supporting. Some of the sampling equipment is range of those. very new. Some of it is, literally, only now being developed. Q83 Lord Patel: Including organophosphates? Dr Dowdall: Organophosphates have been looked Q87 Lord Patel: Do you have an opinion on whether for. I believe the organophosphates element of this is it is easy to identify a fume event? something of a red herring. I think that is an issue Mr Wiltshire: My view on this—and I am not an that people have latched on to. I do not believe there expert and I am not involved in in-flight operations— is any significant evidence to suggest that that is even is that the extreme end of a fume event is a visual one, plausible. But it is one of the concerns and, therefore, where you are seeing smoke, and that is probably with the research that is being planned specifically to seen by everybody on the aircraft and that is almost address this issue, organophosphates will specifically a smoke event rather than a fume event. The fume be looked for. As I say, the diYculty we have is trying events people talk about are more where somebody to capture a fume event. smells something that they feel should not be there. As Dr Dowdall has said, everyone has a diVerent perception of that, and a diVerent sensitivity to it. I Q84 Lord Patel: Unless you monitor all flights, how am sure you will get diVerent reports from would you know that an event has occurred? individuals smelling the same air as to what that air Because, by the time somebody reports it, smelt like. I think it is a very diYcult area for us to presumably you cannot sample anything. assess because there is not the technology available to Dr Dowdall: There is not the equipment available that suddenly capture that air at that instant and analyse you can realistically monitor every flight all the time. it. As we have been told, the technology is only Dr Popplestone: This is one of the aims of the research coming along now to allow us to do that. being proposed by the Aviation Health Working Group and I am sure the Aviation Health Unit would Q88 Lord Patel: Are the reports you have had be able to give you more detailed information on related to newer designed aircraft or is it across the that. The plan is that they will use a variety of board? techniques, almost a very broad spectrum approach, Mr Wiltshire: Again, the generality is that the aircraft to identify what is there, if anything, during a fume that have fume events historically have been older event. The fume events, when they occur, can be a aircraft, ones that are currently in the process of duration of seconds or maybe minutes. It is very being phased out. There are two particular aircraft short. So they are trialling a number of detection that are involved. One is a US-manufactured aircraft devices, some that will pick up transient things and and one a UK-manufactured aircraft. Both are some that will do long-term monitoring, to then relatively old. One, as I say, is in the process of being analyse it. I believe the idea then is, if they identify a phased out now and the other is in reduced use in the particular compound be it organophosphate, VOC airline business. The number of incidents, as I say, of or whatever, they can then develop that and hone fume events is very small and that also makes it very down to try to get more information on that specific diYcult to capture a fume event. It means that we will chemical. One of the diYculties is that we do know have to monitor a large number of flights in order to that if anything is in there it is in very, very minute capture just one event. concentrations. Q89 Earl of Selborne: Following up on this point Q85 Lord Patel: It depends how toxic it is. about how impractical it is to monitor a large number Dr Popplestone: Yes, but we do not know what it is. of flights to catch just the occasional fume event— Anything that has ever been measured has, I believe, and that I understand—presumably you can always been well below the threshold levels for known analyse the HEPA filters once they have come in for toxicity. Clearly, that is one of the things that should maintenance. That will tell you what chemicals, if come out of the research. any, have been filtered out by these filters. You have 3844421003 Page Type [O] 30-11-07 13:07:50 Pag Table: LOENEW PPSysB Unit: PAG1

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26 June 2007 Dr Nigel Dowdall, Dr Mark Popplestone and Mr Roger Wiltshire already explained in an earlier question that these absolutely sure that even what we have now will filters cannot by their nature be 100% eVective, so it deliver what we are trying to do. It is a case of what would give you some indication of what these minute technology is available to do that. It is not a simple quantities might be. process. Dr Dowdall: The filters are particulate filters. They are designed to remove small particles. They are not Q93 Lord Howie of Troon: The answer to my designed to remove chemical compounds. Small question is not very far. organic compounds would not be retained by the Dr Dowdall: I think that is a fair comment. filters. The other thing we need to bear in mind is the ventilation flow rates on an aircraft are huge, so, if Q94 Lord Howie of Troon: You are trying your best, you were trying to capture from that mass of air very are you? tiny amounts of compound, it would simply get lost. Dr Dowdall: We are. We are working with the Aviation Health Working Group, the Research Sub- Q90 Earl of Selborne: You would not expect, Group. It is an area of concern. I would like to be able therefore, to find on the filters— to tell the pilots, “This is what you are exposed to Dr Dowdall: The filter would not capture organic when we have a fumes event” be it misting from de- compounds—not chemicals. It is designed to capture icing fluid or a cabin air contamination. particles. Q95 Lord Howie of Troon: You hope to get there Q91 Baroness Finlay of LlandaV: Would the filters some time fairly soon, do you think? capture chemical molecules if they had a carbon layer Dr Dowdall: We hope. in them onto which the chemicals might be absorbed? Dr Popplestone: Many airlines have volunteered to Dr Dowdall: In the technology we are looking at to do help with the work that is being done on this through the research, various materials are designed to absorb the Aviation Health Working Group and the compounds. If you are talking about routine use Committee on Toxicity. The Committee on Toxicity, through the HEPA filters, then I do not think they when they have been looking at the vast amount of would capture them. I am not an expert in filter evidence they have been given in terms of air design. In terms of the issue in which we are contamination, have made some recommendations interested, the exposure and health, the exposure on research being done. The Aviation Health comes from the contaminant getting into the system, Working Group, the Department of Transport are so the person is exposed to it. It is no point then now taking that forward. A lot of this technology is capturing it a bit later on. In terms of using it as a really very experimental, it is frontline, but hopefully means of identifying what people have been exposed it will give the answers on what is available. I know to, because of the volumes you are talking about it from Virgin Atlantic there was one project done would be very, very diYcult. about two years ago monitoring Boeing 747 in routine operation, but, as Dr Dowdall said, it was not Q92 Lord Howie of Troon: Following on this last a simple thing and all they were able to do was exchange of questions, I remind you that one of our monitor some simple things like carbon dioxide and recommendations in the report now some years ago carbon monoxide levels, but it was a huge logistical was that airlines should carry out simple and exercise to do. It is not a simple process doing it. inexpensive cabin atmosphere sampling programmes from time to time and to make provision for spot- Q96 Lord Howie of Troon: Would you be able to sample collection in the case of unusual pick up any problems in the circulation of oxygen circumstances. How far have you got in throughout the aircraft or the pooling of CO near implementing this recommendation? bulkheads or in any other parts of the cabin? 2 Dr Dowdall: In terms of sampling normal operations, Dr Dowdall: In British Airways we did some research it is not something airlines routinely do but there a few years ago looking at the Boeing 777 following have been a number of research projects which have some reports from our cabin crew and we did quite a carried that out. The European Cabin Air Project comprehensive sampling programme comparing the would be one. The National Academy of Sciences in 777 with the 747, the Jumbo. That looked at sampling the States have looked at it. So there have been a air both along the cabin and across the cabin at a number of research projects. I do not think it is number of diVerent points. In terms of oxygen, the feasible to do in routine use. The equipment that we volume of air that passes through that is required for use to do the sampling has to be carefully set up. It ventilation is such that the oxygen level does not has to be calibrated. It is not something that is viable change, it does not significantly decrease. In terms of in routine operations. In terms of those simple spot- CO , again it was fairly consistent throughout the checks, the technology has not been available. We are cabin.2 We did not find any significant variation. And talking about in a research context and we are not you would not expect to with the way the circulation 3844421003 Page Type [E] 30-11-07 13:07:50 Pag Table: LOENEW PPSysB Unit: PAG1

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26 June 2007 Dr Nigel Dowdall, Dr Mark Popplestone and Mr Roger Wiltshire system is designed and the mass of air that is flowing Q102 Lord Patel: Going back to the other question through the aircraft. I had, which was about filters, what is the smallest size of a particle? Dr Dowdall:OV the top of my head, I could not tell Q97 Lord Howie of Troon: Are you satisfied with you. We could certainly find that out and provide your monitoring of the ventilation system as a whole? that information. Dr Dowdall: We operate the aircraft as the aircraft manufacturers have designed and instructed us to do Q103 Lord Patel: If it was chemical, presumably the it. In designing those aircraft the manufacturers have filter gets impregnated with that chemical and you are to meet the regulatory requirements for ventilation, able to say at least whether the chemical existed or which, while the requirements are not not from that filter. comprehensive, do cover specific items, for instance, the amount of air that must be supplied to each passenger and crew member in the aircraft. So, yes, Q104 Chairman: I would speak with experience of those regulatory requirements have to be met and the the filters: the same filters are used in semiconductor ventilation standards in aircraft are, I would suggest, clean rooms and I am a semiconductor engineer. significantly higher than in most buildings. Particles of 50 nanometres and below would probably go through, so certainly molecules go through and some viruses go through. Q98 Lord Patel: What is the oxygen saturation Dr Dowdall: We find with viruses that they have a normally of a flight in cruise? tendency to clump on particles of dust, so although Dr Dowdall: The percentage of oxygen at any altitude theoretically they would pass through, in reality very is the same. It is 21%. The pressure varies with few of them do. altitude. If you take the maximum cabin altitude of 8,000 feet—and the reality is that very few aircraft do Q105 Chairman: While we are on that question, is it get to 8,000 feet—the reduced pressure is equivalent significant to British Airways and Virgin the cabin to about 15% oxygen. That is a level at which the pressure that can be maintained. In my experience, human body is perfectly able to function. people rest far more easily at lower cabin altitudes. Certainly sleep is aVected by an altitude of 8,000. Is it significant that some aeroplanes are oVering a lower Q99 Lord Patel: Function as against comfort, cabin elevation? maybe. Dr Dowdall: Are you talking about the new Dr Dowdall: There is no eVect on comfort. If you look aeroplanes that are being developed? at ventilation and the respiratory physiology, at 8,000 feet, in a healthy human, you will see no Q106 Chairman: The 787 is going to have a physiological impact. The supply of oxygen to the maximum height, the Dreamliner. tissues is equivalent to what you would see at sea Dr Dowdall: It is related to aircraft construction and level. the impact of the diVerential cabin pressure on the life of the aircraft and fatigue. The 8,000 regulatory Q100 Lord Patel: Going back to the question about maximum goes back many years and relates to ill patients, somebody whose oxygen perfusion is assessments that were done at war time on healthy poor anyway because of respiratory disease, and they young airmen. Yes, in an ideal world we might all say, are on a long-haul flight of eight hours and they have “Let’s have a sea level cabin pressure”. The reality is an oxygen saturation of 15%, that has no health that with the technology we have had, that has not eVect? been viable. Although, for example, Concorde, with Dr Dowdall: Not oxygen saturation. Saturation is a its much smaller dimension cabin, was able to diVerent measure. accommodate a much higher cabin diVerential pressure. It also did not fly as many flights, so fatigue was less of an issue. But, yes, the new construction Q101 Lord Patel: I understand that. techniques using composites oVer the potential for Dr Dowdall: If you are talking about somebody who the aircraft to be able to be pressurised to a lower has lung disease, then, going back to the questions we level. How important that is from a health issue, is were talking about earlier, it is contacting airlines to something that people are interested in. Indeed the say, “I have these medical problems, I would like to Aerospace Medical Association is just in the process travel, what do I need to do?” In those situations, of completing a report that looks at the evidence that many, although not all airlines, are able to provide reducing cabin pressure will be beneficial to health. I supplementary oxygen. If we have people travelling believe the conclusion of that is that the evidence to who do have lung disease, who do need oxygen on support that will be limited. I think it perhaps is more flight, that provision could be made. of benefit to those relatively small number people 3844421003 Page Type [O] 30-11-07 13:07:50 Pag Table: LOENEW PPSysB Unit: PAG1

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26 June 2007 Dr Nigel Dowdall, Dr Mark Popplestone and Mr Roger Wiltshire who have conditions that will be aVected by hypoxia, likely to be lifestyle related. The lifespan of pilots so the people with the chronic lung disease. Fewer of was, on average, longer than comparable them will require oxygen in order to be able to travel. populations. We have that mortality data. In terms of Mr Wiltshire: One point of contact, of course, is ill health retirements, which we have looked at, the many, many people in the world, millions, live in largest percentage of ill health retirements is for altitudes that one experiences in an aircraft cabin. It cardiac reasons and the second largest is for is quite a normal thing to live quite happily at that psychiatric reasons. Neurological conditions have altitude. not featured. We have those broad-brush data. I do not think they necessarily would inform the issues of Q107 Chairman: However, I note that the football fumes contamination. players’ association, whatever that is called, has decided they are not going to have matches above a Q109 Chairman: Let me finish with a question about certain height. low cost airlines. They are widely perceived to cut Mr Wiltshire: I think for extreme sport and energy costs wherever they can, possibly to the detriment of use, but I am talking about living in the context of comfort or health to passengers. Do you think this is sitting around or walking very gently. Certainly a legitimate concern? exercise or extreme exercise in altitude, and I have Mr Wiltshire: The short answer is no. Low cost experienced that myself, gets more diYcult the higher airlines, as the phrase is often used, is really a the altitude. description of the new business model in the short- Chairman: I think you acclimatise. Frequent flyers do haul arena. Bearing in mind many medical problems better than your non-frequent flyers. in the discussions we have had today are about long- haul flying and the issues to do with long-haul flying. Q108 Earl of Selborne: Going back to Lord Broers’ We are talking here about short-haul flying, where a question about the medical data which you must new business model was introduced a few years ago hold, you appear not to be able to give us much meaning that airlines will now operate very assurance that such data as could reasonably be eYciently. It is not a matter of cutting costs, it is made available to the AHWG-sponsored research operating at the lowest unit cost through operating would be made available. Surely every member of the their aircraft very eYciently, filling their aircraft very crew, pilots included, of course, must have regular eYciently, and flying in the most eYcient way. The medical assessments. There will be cases inevitably, result of that is that those airlines are very interested in every industry, where there will be a whole range in flying in the most fuel eYcient way and often are of reasons why people may be considered no longer attracted to the most modern, most fuel eYcient fit for the job for which they are employed. This is aircraft. In many ways, those airlines often introduce raw data which clearly does not have to be attributed the newest aircraft as fast as they possibly can. It is to persons—that would be most inappropriate—but very similar to the tendency of charter airlines, who I it gives you information which surely can be think were the original low-cost airline but sold in a presented. If it did show, for example, that there were more packaged way—also were looking for eYciency cabin crew with neurological abnormalities or wherever they could find it and often introduced cognitive impairment which was greater than might newer aircraft with higher fuel eYciency as fast as be expected, this would be relevant data. If, on the they could. By introducing newer aircraft, in many other hand, there were not such instances, this would ways they are operating just like any other airline, also be relevant data. Why can you not make that and are bringing in the newest technology and the sort of data available? newest cabin environment technology to passengers Dr Dowdall: In terms of pilots and their routine The fact that they have a simple standard product I medical examinations, we do not require our pilots to do not see has any impact on health. Comfort attend British Airways health service to have their obviously is a personal issue, but, as I have medical. A substantial proportion do but many do mentioned in a previous answer, all airlines, be they not. In terms of those baseline data, the CAA medical low-cost, charter or whatever are operating within department are the ones who hold most data. They the regulations on seat pitch. have data for all the UK airlines. In terms of long- term health, British Airways has done probably the Q110 Chairman: Do you think they do enough to most comprehensive study of pilot mortality, where ensure their passengers drink enough fluids during we followed our pilots: we obtained data from the flights. pension fund as to when pilots died and we were able Mr Wiltshire: This is a short-haul issue, where I do to get death certificates. So we have done a very not think dehydration is really an issue. The fact that comprehensive study of pilot mortality and that did those airlines often do not provide fluid or provide not show any significant increases in mortality from little fluid, and what they do they charge for, any causes other than melanoma, which it is thought passengers are almost encouraged to purchase a 3844421003 Page Type [E] 30-11-07 13:07:51 Pag Table: LOENEW PPSysB Unit: PAG1

24 air travel and health: evidence

26 June 2007 Dr Nigel Dowdall, Dr Mark Popplestone and Mr Roger Wiltshire snack and a drink in the departure lounge. There is an Mr Wiltshire: No. I believe the situation before the issue for aviation as a whole, if I may widen this recent security rules were introduced meant that answer to the recent security regulations, where some airlines were almost encouraging passengers to carriage of liquids is now being controlled very take cabin baggage onboard, which often the seriously, perhaps with too much rigour, because it passengers wanted to do themselves. Many does mean that passengers who previously, especially passengers would like to travel just with hand on long journeys, took their own personal half a litre baggage if they can. Airlines are obviously bottle of liquid with them now feel less comfortable constrained by the amount of space they have getting onboard the aircraft because they have not onboard the aircraft, which means that airlines often been able to take that liquid with them. put a size or weight constraint on that piece of baggage or pieces of baggage that go into the cabin. The current regulations often constrain airlines much Q111 Chairman: Do you have any concerns about further than perhaps they would want to constrain the luggage situation overall? There was the time their passengers. We would always try to meet the when because some airports, perhaps notoriously needs of the passenger within the constraints of the Heathrow, became so slow in getting their luggage oV aircraft, but, as I say, security at the moment is the planes and to the passengers, passengers would tending to put a constraint beyond that. try to carry everything with them if they possibly Chairman: Thank you very much for your answers to could, which meant that the cabins became quite our questions. They will be very useful to our inquiry. overcrowded. I suppose the new regulations with the If anything else occurs to you that you think would terrorism have cut that back again. Do you have any be useful to us, please write to us or let us know in concerns about the amount of luggage that ends up in some way. We are very grateful to you for giving up the cabins? your time this morning. Thank you very much. 3844421004 Page Type [SO] 30-11-07 13:08:07 Pag Table: LOENEW PPSysB Unit: PAG2

air travel and health: evidence 25

TUESDAY 10 JULY 2007

Present Broers, L (Chairman) Perry of Southwark, B Colwyn, L Platt of Writtle, B Finlay of Llandaff, B Selborne, Earl of Haskel, L Sutherland of Houndwood, L Howie of Troon, L

Memorandum by Dr Sarah MacKenzie Ross MA, MPhil, C.Psychol, DPsychol, AFBPsS

Re:AirTravel andHealth—Submission ofNewEvidence 1.1 I am a Consultant Clinical Neuropsychologist based at University College London and I would like to submit new evidence that has been produced since 2000 on the health eVects of air travel. In particular, health eVects associated with exposure to engine oil fumes in the aircraft cabin. 1.2. Throughout 2005 and 2006 I examined a number of pilots who complained of ill health following reported exposure to contaminated air on commercial aircraft. I prepared a report detailing my findings for the Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment, entitled Cognitive function following reported exposure to contaminated air on commercial aircraft: An audit of 27 airline pilots seen for clinical purposes. 1

Summary ofMyReport 2.1 I identified a profile of cognitive deficits in pilots which involves under functioning on tests of working memory, verbal memory, attention, mental flexibility and information processing speed. These deficits can not be attributed to factors such as mood disorder, anxiety disorder, malingering or chance. 2.2 My findings are of obvious concern as they pose a risk to flight safety. A pilot’s job involves complex three dimensional thought processing and a need to accurately interpret, shift attention between and respond to changing information presented to them by flight instruments, navigation systems and air traYc controllers. 2.3 The pilots I examined were tested during the day and were asked to perform to the best of their ability, yet deficits were identified. These deficits may be magnified under particular working conditions, such as when a pilot is fatigued after a long shift at work or under stress in a complex emergency situation. 2.4 My report has been considered by the Committee on Toxicity (COT), and they arranged for it to be peer- reviewed by an independent expert and Professor of Neuropsychology who concluded that my study was well designed, had been conducted with an appropriately high level of expertise; and that the deficits/abnormalities identified were striking and of suYcient severity to cause concern about the functioning of implicated aircrew.

2

Summary of aScientificPaperDescribing aSingleCaseStudy, recently published inTheJournal ofOccupationalHealth andSafety,Australia andNewZealand in 2006 3.1 In this paper we conclude that: Potential contamination of aircraft cabin air by engine oil fumes is a serious aviation safety concern for both crew and passengers and further research is needed to determine the potential toxicity of pyrolised engine oil under aviation conditions (ie at altitude, in a reduced oxygen environment, after being subjected to extreme temperature). The medical profession should develop internationally agreed medical protocols for the evaluation and treatment of aVected individuals. Aircrew who report ill health

1 function following reported exposure to contaminated air on commercial aircraft: An audit of 27 airline pilots seen for clinical purposes, by Dr Sarah Mackenzie Ross. 2 A report prepared for the Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment, entitled Cognitive psychosomatic disorder or neurological injury? The Journal of Occupational Health and Safety, Australia and New Zealand (22) 521–528. S J Mackenzie Ross, A C Harper, J Burdon (2006). Ill health following reported exposure to contaminated air on commercial aircraft: 3844421004 Page Type [E] 30-11-07 13:08:07 Pag Table: LOENEW PPSysB Unit: PAG2

26 air travel and health: evidence following exposure to contaminated air should be referred for further investigations, including psychology, neurology, neurophysiology, neuroimaging and respiratory. Diagnoses such as “industrial hysteria” and “psychosomatic disorder” are unhelpful and misleading and should only be made if there is clear evidence that psychological factors are involved in the aetiology of a patient’s complaints. Absence of underlying pathology following medical examination is not proof of an actual non organic condition, particularly in the context of a history that might reasonably account for the symptoms.

FurtherResearch has beenPublished since 2000 that mayInvalidate theConclusionsDrawn by the Committee in 2000 4.1. For example, the Committee focused heavily on the presence of one chemical isomer of Tricresyl phosphate, namely, Tri-orth-cresyl phosphate (TOCP) to ascertain the potential risk to passengers and crews of developing ill health following exposure to engine oil fumes. The Committee concluded that the low levels of TOCP that might be found following an oil leak would not pose a “significant risk to the health of passengers and crew”. 3 4.2 However, it is important to consider (a) other more toxic TCP isomers which are present in much higher concentrations than TOCP and have higher toxicity; and the combined, synergistic eVects of all of the chemicals present in engine oil (see below). 4 4.3 Recent research has shown that adverse eVects may be caused by impurities and/or other5 constituents of the formulated products (eg solvents), as opposed to the active ingredients; and there may be synergistic eVects of chemical combinations. Combined exposure to other chemicals which cause oxidative stress can decrease the level required to produce neuronal damage following exposure to organophosphates. Animal studies have shown that when two chemicals are combined (eg an OP plus DEET) severe neurotoxic eVects were seen in the peripheral6 and central nervous system and increased mortality even though safe levels of each chemical were chosen. In other words when certain chemicals are combined, even at safe levels, the end product can be more toxic than7 what would be predicted from the known properties of each chemical which makes up the mixture. Furthermore, toxicological testing needs to consider health outcomes other than the extremely rare condition known as OPIDN. Physical, cognitive and emotional consequences of exposure should be considered first.

4.4 It is also important to consider the possibility that genetic diVerences between8,9, 10, 11 individuals may render some people more susceptible to the toxic eVects of certain chemicals than others. A number of papers have been published since 2000 which find an association between genetically determined polymorphisms and the development of ill health following exposure to organophosphate pesticides.

Recommendations—Gaps in theEvidenceBase 5.1 Given the scientific uncertainty regarding the potential hazards of inhalation of pyrolised engine oil, further research into the full range of health eVects from inhalation of heated or pyrolised synthetic jet oils is definitely warranted. This research should consist of: (a) On board monitoring to determine the contaminants and level of each contaminant that enters the aircraft. The Committee recommended in 2000 that airlines carry out cabin atmosphere sampling (see paragraphs 1.25 and 1.26) and undertake real time monitoring of air quality (see paragraph 1.43 (c);

3 and Cabin Air Quality International Aero Industry Conference, held at Imperial College, London 20–21 April 2005. Published by the British Airline Pilots Association (BALPA) and the School of Safety Science, University of New South Wales, Sydney NSW 2052. 4 C Winder. Hazardous chemicals on jet aircraft: Case study—jet engine oils. In C Winder ed Proceedings of the BALPA Air Safety and Chemical Toxicology, 41, 1–13. 5 6 Karalliedde, LD, Edwards, P and Marrs, TC (2003) Variables influencing the toxic response to organophosphates in humans, Food following concurrent exposure to pyridostigmine bromide, DEET, and chlorpyrifos, Fundamental Applied Toxicology, 34, 201–22; Abou-Donia,Furlong, presentation M (2005) given Organophosphorus to DEFRA in 2006. ester-induced chronic neurotoxicity, Archives of Environmental Health, 58(8), 484–497. 7 Abou-Donia, M, Wilmarth, K R, Abdel-Rahman, A, Jensen, K F, Oeheme, F W and Kurt, T L (1996) Increased neurotoxicity pesticides: A pilot study. Journal of Occupational Health and Safety: Australia and New Zealand (in press, April 2007). 8 Spolymorphisms J Mackenzie Ross, in farmers J S Clark, attributing V Harrison, ill health Kto M sheep Abraham dip. The (2007). Lancet Cognitive, 359, 763 impairment"4. following exposure to organophosphate 9 Cherry,susceptibility N, Mackness, to organophosphorus M, Durrington, poisoning P, Povey, in farmers A, Dippnall, dipping sheep. M, Smith,Pharmacogenetics, T and Mackness, 13 (2), 81–88. B (2002) Paraoxonase (PON1) 10 Mackness,susceptibility B, for Durrington, organophosphate P, Povey, toxicity. A, Thomson, Biomarkers S, Dippnall,, 8 (1), 1–12. M, Mackness, M, Smith, T and Cherry, N (2003) Paraoxonase and 11 Costa,on pesticide L G, sensitivity, Richter, R cardiovascular J, Li, W F, Cole, disease, T B, and Guizzetti, drug metabolism. M and Furlong, Annual Review C E (2003) of Medicine Paraoxonase, 54, 371–392. (PON 1) as a biomarker of Costa, L G, Cole, T B, Jarvik, G P snf Furlong C E (2003) Functional genomic of the paraoxonase (PON1) polymorphisms: eVects 3844421004 Page Type [O] 30-11-07 13:08:07 Pag Table: LOENEW PPSysB Unit: PAG2

air travel and health: evidence 27

(b) An Epidemiological Survey to determine the incidence and prevalence of ill health in aircrew and any association there might be with exposure to contaminated air. A sub-sample of aircrew should also undergo clinical examinations by a multi-disciplinary group of healthcare professionals to explore the nature of any symptoms identified in more depth, determine severity and impact on life, ascertain whether there are subgroups of people at particular risk (eg the elderly, pregnant women, children, persons of less than average health). The House of Lords Science and Technology Select Committee recommended in 2000 that maximum value should be extracted from the medical records of aircrew concerning any long-term eVects from exposure to the aircraft cabin environment—see paragraph 1.43 (f); (c) A survey needs to be undertaken to determine whether passengers are aVected by exposure to engine oil fumes on board aircraft; (d) Toxicological testing needs to be undertaken that takes account of the potential synergistic eVects of the range of diVerent chemicals found in engine oil; and this research should consider health outcomes other than OPIDN, such as physical, cognitive and emotional disorder; (e) The current edition of the Department of Health book aimed at professionals should contain information about the potential health eVects of exposure to engine oil fumes; (f) Whilst this research is being undertaken, the Government and regulators should re-consider (a) supplying only fresh air to the flight deck (see paragraph 1.24) and/or (b) installing filters to minimise the risk to aircrew and passengers of engine oil fumes. 7 June 2007

References Haley, R W, Billecke, S, La Du, B N (1999). Association of low PON1 Type Q (Type A) arylesterase activity with neurologic symptom complexes in Gulf War veterans. Toxicology and Applied Pharmacology, 157, 227–233. Richter R J and Furlong, C E (1999). Determination of paraoxonase (PON1) status requires more than genotyping. Pharmacogenetics, 9: 745–753.

Memorandum by the WRIGHT Project Scientific Executive Committee

The WRIGHT Project

In March 2001, the World Health Organization (WHO) convened an international meeting on air travel and venous thrombosis at which experts on venous thrombosis (VT) and representatives of airline companies, the International Air Transport Association (IATA), the International Civil Aviation Organization (ICAO), the European Commission and consumer groups participated. The objectives were to review the scientific information concerning air travel and VT, identify gaps in knowledge and develop priority areas for research. It was concluded that a link probably existed between air travel and venous thrombosis and that similar associations possibly existed for other forms of travel. It was decided to set up a set of studies, consisting of: — Epidemiological studies to determine whether there is a link between air travel and venous thrombosis the absolute risk if such a link exists and the size of the problem. These studies would also provide clues to other aetiological factors; — Special studies using intermediate end-points in groups of volunteers to examine isolated independent environmental and behavioural risk factors; — A prospective intervention study involving passengers, using objective diagnostic methods and examining various preventive measures. The WRIGHT project (WHO Research Into Global Hazards of Travel) was funded by the United Kingdom Department for Transport and Department Health and the European Commission. Both the epidemiological and the pathophysiological substudies were completed in Phase I. A substudy, elaborated in the original protocol, into methods of prevention has been deferred to Phase II. 3844421005 Page Type [E] 30-11-07 13:08:07 Pag Table: LOENEW PPSysB Unit: PAG2

28 air travel and health: evidence

Summary ofResults of WRIGHT –PhaseI

Population-based case control study As an extension of a very large population-based case-control study (MEGA: Multiple Environment and Genetic Assessment of risk factors for venous thrombosis), we examined the eVect of all modes of travel on the risk of a first thrombosis. The study included 1906 patients aged less than 70 years, presenting with a first venous thrombosis along with the same number of matched controls (n%3,812 in total). The combined eVect of travelling and the risk factors for thrombosis (factor V Leiden, prothrombin 20210A mutation, body mass index [BMI] and height) was assessed. Travelling for more than four hours increased the risk of VT 2-fold (odds ratio 2.1, 95% CI 1.5 to 3.0), compared to not travelling. The risk of flying was similar to the risk of travelling by car, bus or train. Travel by car, bus or train led to a high risk of thrombosis in individuals with factor V Leiden mutation (relative risk 8.1, 95% CI 2.7 to 24.7), those who were more than 1.90m tall (relative risk 4.7, 95%2 CI 1.4 to 15.4) and those who used oral contraceptives (estimated relative risk(20). These synergistic eVects were more apparent with air travel. In addition, people shorter than 1.60 metres had an increased risk of VT after air travel only (relative risk 4.9, 95% CI 0.9 to 25.6). Obese individuals with a BMI of more than 30kg/m had an increased risk. The more pronounced risk increase observed after air travel compared to ground travel for some of these risk factors may suggest an eVect of flight-related factors, which are absent during travel by other modes of transport.

Retrospective cohort study among employees of international organisations This was a retrospective cohort study among employees of international companies and organisations. Data concerning the occurrence of VT, risk factors for VT and habits during air travel were linked to the organisation’s travel database. Exposure was defined as four weeks after a flight of four hours or longer. A total of 315,762 flights were included in the analysis, of which 100 208 were of more than four hours duration. The incidence of VT after a flight was 3.2/1,000 persons per year (95% CI 2.0 to 4.7), compared with 1.0/1,000 per year (95% CI 0.7 to 1.5) in the non-exposed time. This yielded a relative risk of VT after a more than four- hour flight of 3.2 (95% CI 1.8 to 5.6) in this population. The absolute risk of VT per flight in this population was 1/4,656. The absolute risk was greater if multiple journeys were taken in the four-week exposure period, and increased with duration of flight, up to one per 1,200 for flights of 16 hours or longer. Again, higher risks were found for women who used oral contraceptives, and in individuals who were short, tall or overweight.

Hypobaric hypoxia study The study was conducted between September 2003 and November 2005 in the United Kingdom whereby a single-blind crossover design was used to compare the eVects of prolonged sitting in a hypobaric hypoxic environment with those of sitting for the same period in a normobaric normoxic environment. 73 healthy volunteers participated in the study and were assigned to one of three groups (Group I: individuals between the ages of 18 and 40 years without known risk factors for VT, n%49; Group II: women between the ages of 18 to 40 years who were taking a combined oral contraceptive pill, n%12; Group III: individuals aged 50 years or older, n%12). Significant changes in several markers of coagulation activation and fibrinolysis were observed during the normobaric exposure, attributed to prolonged sitting and circadian variation. However, no significant diVerence was observed in the overall change of any marker between the normobaric and the hypobaric exposures.

Travel and non-travel immobility study This study aimed to disentangle the possible aetiological factors involved in the promotion of the postulated hypercoagulability occurring during flight. The study used a crossover design in which volunteers were exposed to an eight-hour flight and to two control situations comprising immobility on the ground and daily activity. The study was conducted between 24 May and 10 July 2004 with healthy volunteers, many of whom had risk factors for thrombosis such as the factor V Leiden mutation or oral contraceptive use. All participants were exposed to an eight-hour flight, an eight-hour movie marathon and eight hours of their usual daily activities, with at least two weeks between each exposure situation. Blood samples were drawn before, during, and after each exposure. Seventy-one healthy volunteers aged 18-40 years took part in the study, 15 men and 56 women, of whom 26 were asymptomatic carriers of the factor V Leiden mutation; 30 women used oral contraceptives (15 with and 15 without the mutation). After the flight, median thrombin-antithrombin (TAT) complex increased by!30.1%, while it decreased by"2.1% after the cinema and by"7.9% after the daily 3844421005 Page Type [O] 30-11-07 13:08:07 Pag Table: LOENEW PPSysB Unit: PAG2

air travel and health: evidence 29 life situation. This was most evident in the group with factor V Leiden who used oral contraceptives. We found a high-response in TAT values in 17% of the individuals after air travel (3% for movie marathon; 1% in daily life). The high-responders were mainly women with the factor V Leiden mutation who used oral contraceptives. A high-response in all parameters (prothrombin fragment 1 and 2 (F1!2), TAT and D-dimer) was found in four individuals (6.3%) after the flight and not in either of the two control situations.

Unresolved questions Although many issues have been resolved in WRIGHT Phase I, some questions are still unanswered and new ones have been raised, which relate to the underlying mechanism of air travel-related thrombosis, and to modes of prevention. Hypobaric hypoxia is one of the factors that travellers will encounter during air travel but not during ground travel. The results of the hypobaric chamber studies with healthy volunteers predominantly without risk factors for VT failed to demonstrate any association between hypobaric hypoxia and prothrombotic alterations in the haemostatic system. However, the travel and non-travel immobility study, which included a high proportion of individuals with risk factors, suggested that some flight-specific factor may interact with pre-existing risk factors and result in increased coagulation activation in susceptible individuals over and above that related to immobility. Further study will be required to determine the identity of the culpable factor. In view of the substantial number of people undertaking long-haul air travel and the fact that many travellers will have one or more known or unknown risk factors for thrombosis, air travel-related VT is an important public health issue. There is a clear need for travellers to be given appropriate information regarding the risks and for further studies to identify eVective preventive measures. At the moment, there is a complete lack of data on the eYcacy and safety of methods to prevent air travellers’ thrombosis. Hence, guidelines are contradictory, illustrated by a study, also performed within the WRIGHT project, among 1,600 professionals employed in the field of thrombosis and haemostasis. Travelling to Sydney for a conference in this field, 80% of the respondents used preventive measures. The form of prophylaxis varied widely, from exercise to the use of anticoagulant medication by 10% of the delegates. To date, no studies on the optimal prevention of clinical thrombosis have been performed, mainly because they will require large sample sizes, as the condition is relatively infrequent in an average flying population. To solve this, some investigators have performed intervention trials with asymptomatic thrombosis as endpoint. Asymptomatic clots can be found by ultrasound scans of the legs, and as they are much more frequent than symptomatic events (3% of passengers), the sample sizes can be much reduced. Whilst useful in showing that clots form often during air travel, and that prevention is possible, the clinical relevance of these studies is uncertain. In designing preventive studies it therefore makes most sense to target those individuals who are increased risk.

Conclusion Several studies were performed during Phase I of the WRIGHT project to investigate the magnitude of the risk, the eVect of other factors on the risk and the mechanism by which air travel leads to VT. The findings of the epidemiological studies indicate that the risk of VT increases by approximately three-fold after a long-haul flight. This increased risk applies to other forms of travel (such as car, bus or train) where travellers are exposed to prolonged seated immobility. The risk increases with the duration of travel and with multiple flights within a short period. The incidence of VT after a long-haul flight was estimated to be one in several thousand travellers. Obesity, height, use of oral contraceptives and the presence of prothrombotic blood abnormalities or variant were identified as contributors to the increased risk of travel-related VT. The pathophysiological studies supported these findings. Two billion people per annum travel by air. The results from the WRIGHT project indicate that over 150,000 of them will develop venous thrombosis, of whom 7,500 will suVer a fatal pulmonary embolism. While the risks and risk groups have now been clearly identified, there is no clarity about eVective and safe prevention. For this reason it is essential that prevention study of the type proposed for Phase II of the WRIGHT Project is carried out and that future passengers will be adequately informed about their risk and the optimal mode of prevention of travel-related venous thrombosis. 18 July 2007 3844421006 Page Type [E] 30-11-07 13:08:07 Pag Table: LOENEW PPSysB Unit: PAG2

30 air travel and health: evidence

Examination of Witnesses Witnesses:ProfessorMichaelBagshaw, Aviation Medicine Director, King’s College London,DrSarah MacKenzieRoss, Consultant Clinical Neuropsychologist, University College London,ProfessorHelen Muir, Professor of Aerospace Psychology, Cranfield University andDrWilliamToff, Senior lecturer in Cardiology, University of Leicester and member of the WRIGHT Project Scientific Executive Committee, examined.

Q112 Chairman: Thank you for coming to give later, and as a result of your original report, the evidence to us at this session. I am sorry you are so far Aviation Health Unit was established at the Civil away but I hope the sound system will cope with that. Aviation Authority whose remit is to oversee Welcome, members of the public. There is a note research, not to do research. If we look across the outside on the remit of this Committee, if you would topics that were raised by the previous Committee, for like to pick that up. I suggest that we start by you example deep vein thrombosis, cabin air quality, introducing yourselves and, if you wish, making an fatigue issues, transmission of infectious disease and opening statement. Can we start with you, Professor so on, the only substantive research we have had has Bagshaw? been from the WRIGHT study from the World Professor Bagshaw: I am Professor Michael Bagshaw. I Health Organisation, and the research that has been am Director of Aviation Medicine at Kings College done on cabin air quality has been supported by the London, a post I took up following my retirement European Union under the fifth framework and now from British Airways where I was Head of Medical under the sixth framework and this is pan-European, Services for 12 years. as opposed to UK-led. There is very little input from Dr MacKenzie Ross: Hello, my name is Dr Sarah Her Majesty’s Government into research in the MacKenzie Ross. I am a consultant United Kingdom and I believe that this is a pity. The neuropsychologist at University College London and fact that you have convened this committee suggests my area of expertise over the last few years has been that there are still unanswered questions and I would toxicology, in particular looking at whether low-level like to see more focus. In my own department I am exposure to organophosphates is harmful to health. I responsible for post-graduate teaching and I give a lot am funded by Defra for this work. The reason I am of input to advise on research, but I do not in fact here is that I have seen a number of pilots over the last conduct any research. My university does not fund two years who report ill health. research in civilian aviation medicine and there is no Professor Muir: My name is Helen Muir. I am the source of funding. Professor of Aerospace Psychology at Cranfield University and my particular expertise is passenger Q114 Chairman: What is the worldwide situation behaviour and cabin crew behaviour in normal flight with academic study of this problem? and also in aircraft emergencies. Professor Bagshaw: By “problem”, are you indicating Dr Toff: I am Dr William ToV. I am Senior Lecturer in that there is a problem? Cardiology at the University of Leicester and I have a long-standing interest in aviation cardiology since working for the CAA in the early 1980s. For the past Q115 Chairman: Looking into airline health in six years I have been a member of the Scientific general and for passengers especially. Executive Committee and one of the investigators for Professor Bagshaw: The Aerospace Medical the WRIGHT project, investigating the link between Association is the umbrella organisation DVT and air travel. internationally. The Air Transport Medicine Committee of the Aerospace Medical Association does oversee research and brings together the results Q113 Chairman: Thank you. Would any of you like ofresearchandsponsors panelsattheannualscientific to make an opening statement? If not, we will go congress.The InternationalAcademy ofAviation and straight into the questions. My first question is for Space Medicine also sponsors an international you,ProfessorBagshaw.Youaretheonlyprofessorof congress and papers are presented. In the past we have aviation medicine in the UK at present, as we relied on the airline industry to provide the research. understand it. Do you think research in this area is In my own time at British Airways, research was done given suYcient priority? Has the position improved into pilot morbidity and mortality, cosmic radiation, since the year 2000? cabin air quality and so on. With the change in the Professor Bagshaw: I believe that awareness has risen structure of funding of the airline industry with the and with that research is going on throughout the advent of the low-cost airlines, there is not the world; there is frequent reference back to the report of willingness or indeed the funding available to support your Committee from 2000. In reality, it is fair to say that research, so we look to the United States. The that there is insuYcient research in the UK. Her ASHRAE Committee, the American Society of Majesty’s Government contributed to the WRIGHT Heating, Refrigeration and Air-Conditioning project on DVT, which you are going to hear about Engineers, have a sub-committee on standards for 3844421006 Page Type [O] 30-11-07 13:08:07 Pag Table: LOENEW PPSysB Unit: PAG2

air travel and health: evidence 31

10 July 2007 Professor Michael Bagshaw, Dr Sarah MacKenzie Ross, Professor Helen Muir and Dr William Toff cabin air and they are supporting research now at a changes in blood-clotting parameters between a number of American universities. Again, we look normobaric exposure and a hypobaric exposure. across the Atlantic for our data. What we did not do was to look at the higher risk people, for example people who had combinations of Q116 Chairman: Do these people turn up at the risk factors such as pill use and an inherited international conferences and you participate in those thrombophilia.Wehadsome diYcultyrecruitingsuch conferences, so we have access to that? people. There are very few people in the UK who will Professor Bagshaw: Indeed; yes. Both the routinely prescribe contraceptive pills to people who organisations I mentioned are truly international. In are known to have a thrombophilia. In the Dutch fact I was president of the Aerospace Medical cohort who went on the flight study that was Association which indicates the breadth of the deliberatelyenrichedandincluded15suchpeoplewho international dimension. The next meeting of the did in fact have that combination of risk factors. What International Academy of Aviation and Space they found in the flight study was that the higher risk Medicine is in Vienna at the end of August/beginning individuals did tend to show some increased of September and I have seen the draft programme; a coagulant changes in the flight compared with when number of passenger health issues will be addressed at they were studied after a similar exposure sitting in a that congress. cinema for the same length of time.

Q117 Baroness Perry of Southwark: Could you tell us Q119 Baroness Perry of Southwark: In the light of all what you see as the really key findings of the this, what do you think should be done to reduce the WRIGHT project? risk to those vulnerable groups when they come to Dr Toff: The aims of the study, as you know, were to check in or when they buy their tickets? quantify the risk of venous thrombosis associated Dr Toff: It is important that we focus on public with air travel, to clarify who is at risk and then to go education, letting the public know that there is a risk on to look at possible interventions to reduce the risk. and advising them of the general measures that they The primary finding was that overall the risk after can take across the board such as avoiding excessively travel in excess of four hours’ duration by any mode is prolonged periods of immobility without even increased two-fold. So long-haul journeys by any exercising the legs or getting up to walk around; that is mode, whether it be car, bus, train or plane, increase not just for air travel, that is for any sort of journey. your risk two-fold. We know that there is an Going beyond that, we need to make sure that people interaction with other risk factors, so that if you who are at increased risk understand that they have already have pre-existing risk factors, your risk will risk factors and should be considering and discussing increase in a way which may be more than additive. with their physician the possibility of other What we found in the study was that, in addition to interventions that might be helpful in the higher risk these synergistic eVects being seen in all modes of group. Those might include, for example, wearing travel, there was some suggestion that they were more graduated compression stockings, use of a pronounced in air travellers. We went on to look at subcutaneous heparin injection in the highest risk mechanisms and specifically to answer the question as people and possibly the use of mechanical devices, to whether hypobaria and hypoxia in the airline cabin which are now available in small battery-powered might actually contribute to the risk of thrombosis, versions, perhaps for higher risk people who are but we found no evidence of pro-coagulant changes unable to take heparin. What we do not really know is attributable to the low pressure or the low oxygen in the eYcacy of those interventions in this setting. We contrast to earlier smaller and uncontrolled studies. have some data from a post-surgical setting and it is What we did find when we went on to do a volunteer extremely important that we go forward with the flight study is that there is some element of the aircraft second phase of the WRIGHT project which is cabin environment that does appear to confer an designed to look at the eYcacy of diVerent increased risk, which fits with the epidemiological interventions in this specific clinical setting. data, but we are not sure what that factor might be. Q120 Baroness Perry of Southwark: Who is doing the Q118 Baroness Perry of Southwark: As I understand publicity, letting the general public know what the it, when they did this simulation, it did not produce risks are and that they should be discussing with their any diVerences. Is that right? physicians, if they have any of the pre-conditions? Dr Toff: The simulation in the hypobaric chamber Dr Toff: The Department for Transport and the consisted of 73 healthy volunteers. It included 12 Department of Health have done a very good job in people who were over the age of 50 and 12 users of the reflecting the background, the ongoing research and, oral contraceptive pill. In the risk groups and in the very promptly, the findings of that research on their general population there was no diVerence in the websites. The diYculty, as I perceive it, is that most 3844421006 Page Type [E] 30-11-07 13:08:07 Pag Table: LOENEW PPSysB Unit: PAG2

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10 July 2007 Professor Michael Bagshaw, Dr Sarah MacKenzie Ross, Professor Helen Muir and Dr William Toff travellers do not spend a lot of time looking at those Dr Toff: The WRIGHT report itself did not websites and, having recently booked long-haul specifically look at all risk groups across the board. It flights, there is no point in the process at which the risk is a given and you are absolutely right, that would be is even raised or mentioneduntil possibly they read the the highest risk; recent surgery within the last three High Life magazine during the flight and discover that monthswouldberegarded asanimportantriskfactor. there is some circulatory risk. There was no element of the WRIGHT study that specifically looked at that group and in the Q121 Lord Colwyn: Of course you can identify these epidemiological studies the number of such subjects high-risk passengers. Would it not be possible at the would have been very small, so they would not have check-in to take some of them aside and give them a figured in any specific analysis. slightly more comprehensive tutorial on in-flight exercise? Q125 Lord Howie of Troon: You mentioned the Dr Toff: The horse has bolted to some extent by that danger in other modes of travel. Has comparable time. That would be a time at which the generic research been done on a train journey from, say, intervention, in particular the advice to exercise the London to Inverness? legs regularly, at least hourly, could be given and Dr Toff: I am not aware of any specific studies looking subsequently reinforced. It is too late by then to get a at train journeys. There are two or three studies which measured graduated compression stocking, have looked at long bus journeys, looking at clinical appropriately sized for the person. It is too late to outcomes, and blood clotting changes, and they are discuss the risks and benefits of other measures such as concordant with our findings in that they found some subcutaneous heparin. The highest risk people will, in pro-coagulant changes after prolonged sitting on a asense, betoo lateto haveany usefulintervention over bus but they were no diVerent from prolonged sitting and above the general measures, the eYcacy of which in an aeroplane. is unproven in this setting. We know that increased venous flow in the deep veins of the leg is achieved by Q126 Lord Howie of Troon: Coming down here this dorsiflexing and plantarflexing at the ankle; we know morning, I saw a bus travelling from London to that is an eVective manoeuvre to increase flow, but of Aberdeen. Has research been done in that? A bus course it can only be done when you are awake, when journey from London to Aberdeen is fairly lengthy. I you remember and if you are physically able to do it. do notknow quite how longit would take, butI should So for perhaps the frailer elderly person, who is at the not like to undergo it myself. highest risk, there is nothing very much that could be Dr Toff: It is important, not just at the airline check-in, done at the check-in to reduce that risk. but it is important that the general public health message is somehow also communicated. Whether Q122 Chairman: Could you explain to me, as an you are sitting at your computer for 12 hours, sitting engineer, why it is that a compression stocking helps on a bus from Aberdeen for 12 hours or whatever, the flow of blood? there is a risk from prolonged seated immobility, Dr Toff: The short answer is no, but I can tell you what particularly when you have hyperflexion at the knee, other people have told me in answer to the same which impedes the blood flow to some extent, and also question. The general view is that the compression of at the hip. I was telephoned last week by Motorcycle the deep veins in the leg reduces their diameter and News because I believe that the Institute of Advanced thereby increases the rate of flow. The physics of that, Motorists has recently issued a caution for I suspect are well known to you, but it is the reduction motorcyclists undertaking prolonged journeys where in calibre of the vessel that is thought to be the main their leg position is just such as would aggravate the factor. thrombotic tendency.

Q127 Lord Sutherland of Houndwood: I am interested Q123 Chairman: It increases the speed of the blood? inthe lengthof thejourney andyou havespecified over Dr Toff: Yes; the flow rate in the deep veins. The other four hours. To declare an interest, I do rail journeys benefit of stockings, which goes beyond the pure issue four hours each way, once a week, to be here. Is the of venous thrombosis, is that they do undoubtedly frequency of travel relevant? Is there any evidence on reduce ankle swelling which is beneficial in itself and that? helps you to get your shoes back on at the end of the Dr Toff: Yes. There is increased risk associated with flight. They may also reduce the risk of thrombosis taking multiple long journeys in a short period. The secondarily. exact quantification of the risk is complex, but it is greater than if you had just taken a single journey in Q124 Lord Colwyn: The WRIGHT report does not your eight-week risk period. If you take another mention the highest risk of all which is recent surgery. journey, you will get an increment in risk. 3844421006 Page Type [O] 30-11-07 13:08:07 Pag Table: LOENEW PPSysB Unit: PAG2

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Q128 Lord Sutherland of Houndwood: A related the longest flights that are currently planned, there is point. Would taking aspirin help me in these journeys? no risk of exceeding the limits recommended by the Dr Toff: That is a very interesting and controversial International Commission on Radiological area. The evidence from a meta-analysis and post- Protection. The otherthing to consider isthe dry cabin surgical studies in orthopaedic surgery suggests that air. The research on the eVects of very low humidity aspirin might reduce the risk of thrombosis by has looked at simulated flights of eight hours; no work something in the order of 25%. Where you are dealing has yet been done to look at the zero humidity with an issue such as travellers’ thrombosis, where the environment in excess of eight hours. Looking at the absolute event rate is very low, you have to treat a lot data from that study at Farnborough, there is no sense of people to prevent one thrombosis and the estimate of concern in the extrapolation, but we will not know would be something in the region of treating 24,000 until we do the flights. As far as cabin air quality is people to prevent one thrombosis. On the other hand, concerned, there is good evidence and good data to the number that you need to treat for harm from show that the cabin air quality is bacteriologically aspirin is in the region of one in 17,000; that is by way clean because of the use of high eYciency particulate of bleeding or allergic reaction or whatever. In this filters, and there is no suggestion that that will degrade particular instance, where the risk is very low, say for over a long flight. The biggest concern is probably the average traveller, the use of aspirin is a relatively boredom and what to do with yourself during such a ineVective intervention. It does have some benefit but long period of time. We examined the eVects of ultra it is relatively ineVective and the prospect of harm may long haul flights at the IATA Cabin Health outweigh the prospect of benefit. In public health Conference last year held in Geneva where Emirate terms, we would not advocate aspirin as an Airlines and I presented data which was reassuring, intervention for any group and it is not in fact with the exception of the increased risk of deep venous advocated as prophylaxis in any setting for venous thrombosis. thrombosis. Q132 Baroness Finlay of LlandaV: I just wondered Q129 Baroness Finlay of LlandaV: Could you just tell whether Professor Muir would like to talk about the us a little bit about the implications of ultra-long-haul psychological impacts of an ultra-long-haul flight. flights for passengers’ health, perhaps building on Professor Muir: Some of these psychological factors what you said, Dr ToV, and then to others? are not well understood but one thing that is relevant Dr Toff: I do not come forearmed with the specific is that the public expectation of being able to travel figures, but for the longer flights it has been when one is considerably older is changing and the consistently observed that there is a much greater demographics of the population travelling on these increase in risk. Flights in excess of 12 hours and ultra-long-haulflightswill increasinglyinvolveelderly certainly flights in excess of 16 hours would be people, people who perhaps do not have such good associated with a substantially increased risk of general health. I am nervous about using that word in venous thrombosis compared with the shorter flights. the company of the medical profession but there is the issue of people who are perhaps in their 90s going to Q130 Baroness Finlay of LlandaV: You gave us a take a flight with a journey time of 23 hours and then figure before of flights more than four hours giving a you get into the issues of fatigue. I would not have doubling of risk. Do you have further figures on thought there would be psychological diYculties. travelling that goes on for longer than eight hours or 12 hours? Q133 Baroness Finlay of LlandaV: There are posture Dr Toff: There are figures from a number of sources, issues certainly for people who are older, back pain but, to give an example, in a study of pulmonary and so on. I just wonder whether the one-size-fits-all embolism occurring after long-haul travel in people seat of anairline is appropriate in this dayand age with returning to a Paris airport, the particular study the very broad range of passengers, not only in age, showed that overall the risk of pulmonary embolism but in size and shape. was less than one in a million person flights, but if you Professor Muir: There is quite a lot of evidence that had travelled in excess of 12 hours, I believe the figure one-size-fits-all is not the ideal scenario. The problem was four to five per million. is, if we started designing seats for diVerent sizes of people and putting them on aircraft, there would be a Q131 Baroness Finlay of LlandaV: If we broadened quite complex check-in problem. The practicalities of thatfromthrombosistootherriskstohealth,Iwonder that may make it almost impossible to achieve. whether anyone else would like to comment. ProfessorBagshaw: Ihavelookedspecifically attherisk Q134 Baroness Finlay of LlandaV: Should we have from cosmic radiation and I am pleased to advise you minimum stopover times on these very long flights? that the increase in risk is of no significance. Even for Would it make any diVerence? 3844421006 Page Type [E] 30-11-07 13:08:07 Pag Table: LOENEW PPSysB Unit: PAG2

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Dr Toff: As a consumer, I suspect choice is the slower to process information, they had fluctuating watchword. The option to stop over is undoubtedly a attention and they had some diYculties with high- useful thing for the people who, for whatever reason, level functions like multi-tasking. How this translates do not enjoy the long flights. From the point of view of in terms of their job in the aircraft was that they said prophylaxis of venous thrombosis, if you take two that when working they were missing instructions consecutive flights within a relatively short period, the from air traYc controllers, getting numbers regarding risk will not be much diVerent unless you use the heading and altitude and speed the wrong way round, intervening period specifically to exercise. Even then, completing tasks in the incorrect sequence, forgetting the components need to be broken up by periods of whether or not they had done certain things like exercise as well. It probably does not make a great deal lowering the undercarriage and that kind of stuV; so of diVerence from the thrombosis point of view. It is quite alarming deficits were reported and deficits were possible that, if anything,it might actually prolong the confirmed on testing. They also had some evidence of journey time by sitting around in an intervening abnormalities from other medical specialists; so it was airport for an extra hour or two. not just me finding abnormalities, they were found elsewhere too. The main issue was that they believed Q135 Lord Haskel: Just coming back to the question this was due to exposure to contaminated air in the of cosmic risk, which Professor Bagshaw raised, we aircraft. When they came to see me there was no are told that modern aircraft are now being built of particular evidence of exposure that they could carbon fibre composites and all kinds of new present me. Apparently, there is not monitoring on materials. Can we be sure that, with these new aircraft, so they were not able to come with a printout materials, there will be no risk of cosmic risk? of what was coming into the aircraft. What we did was Professor Bagshaw: Yes, the aircraft structure does not to look at whether there were alternative explanations act as a shield. Whatever the material it makes no that we could identify to see whether perhaps they had diVerence. madeanattributionerroranditwasnotcontaminated air at all. We basically looked for common causes of cognitive impairment and the sorts of symptoms they Q136 Lord Sutherland of Houndwood: Dr report. We looked at all their medical notes to see MacKenzie Ross, you carried out a study of 27 pilots whether they had a history of any medical problems, who reported some ill health. Can you summarise very we looked at whether they might have another disease briefly the outcomes and what your findings were? process, a neurological injury of some sort and we Dr MacKenzie Ross: It is important to state that it was looked at whether they might have a mood disorder, not a research study. In addition to being a researcher, whether they might be malingering. We did all of that I am also a clinician and basically over the last two and basically we were able to exclude those years around 40 pilots have come to see me reporting explanations in at least 18 pilots. We had 18 pilots who ill health which they attribute to exposure to hydraulic wereimpairedandilland wecouldfindnoexplanation fluids and jet engine oils in the cockpit. Last year I was for why that was the case and, as I said earlier, they approached by a government committee, the were reporting it was contaminated air. Given that Committee on Toxicity, and asked to present some there is not aircraft monitoring as standard to know interim findings; at that time I had seen 27 pilots. whether or not contaminants are coming in and if they These pilots came to see me either as a medical referral are, on what level, my personal feeling is that it is very or they referred themselves because they were important that some further research is undertaken. concerned about their health, but were very anxious These people are definitely ill; that is beyond a doubt. about notifying the authorities in case they lost their The questionis: why? Theythink it iscontaminated air licence. They came to see me for an assessment both of and, as yet, there does not appear to be any data that cognitive function and also of what we call adult would allow us to prove or disprove that hypothesis. It mental health and mood state. What we found was is absolutely imperative that further research is done. that all bar one of the pilots that came to UCL had basically reported and complained of chronic health problems, including fatigue, sleep diYculties, Q137 Lord Sutherland of Houndwood: Thank you fluctuating gastro-intestinal problems, numbness in very much. That was very, very clear and very helpful. fingers and toes and of interest to me was memory and Is there yet a unified view amongst experts about other intellectual impairment. What we did was to put reported fume events as we might call them or is there them through a very thorough examination process still much uncertainty? that took an entire day for each pilot and the results Dr MacKenzie Ross: As far as I understand it, it is confirmed on psychometric testing that they did accepted in the industry that fume events definitely indeed show evidence of cognitive impairment but in occur. They are reported in many cases, but there is very specific areas. They were not globally impaired also apparently a degree of under-reporting, so it is but they did have very specific deficits in that they were unclear how often they happen, what it is that is 3844421006 Page Type [O] 30-11-07 13:08:07 Pag Table: LOENEW PPSysB Unit: PAG2

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10 July 2007 Professor Michael Bagshaw, Dr Sarah MacKenzie Ross, Professor Helen Muir and Dr William Toff coming into the aircraft and what quantities and what Dr MacKenzie Ross: There is absolutely no research at eVects it might have on people, if any. all in the UK. In Australia there have been reports but, again, by clinicians of case series. There is a great need for research to be done in the UK. I believe the COT Q138 Lord Sutherland of Houndwood: For example, Committee will be making some recommendations in one issue that is bound to occur to one is if you have 27 that area, but yes, we definitely need to do something. pilots out of a profession of however many thousands, Professor Muir: We have not met until today, but I am could you find a similar group amongst lawyers or actually leading a study for the Department for doctors or members of the House of Lords even? Transport in which we intend to do a very Dr MacKenzie Ross: Obviously this is what we call a comprehensive study of the products which are self-selected sample and it is small in comparison to emitted into the cabin. The study has only recently the pool that it is coming from. They are ill, but it is started but we have already had one intervention and unclear how representative they are of their group. we are halfway through a feasibility study. The UK is However, we did compare the performance of these going to collect data on this subject. pilots with what we class as healthy controls; these were people randomly pulled oV the street. The profile Q142 Lord Colwyn: If there is a fume event in the of deficits in the pilots is not the same; there are not cockpit, is there automatically a similar fume event in deficits in people you pull oV the street generally the rest of the aircraft? speaking, so the profile is diVerent. Professor Muir: That is one of the things we will have to look for. Q139 Lord Howie of Troon: Did the ages of these play any part? I have noticed a deterioration in some of my Q143 Lord Sutherland of Houndwood: Have there colleagues. been reports from passengers comparable to those Dr MacKenzie Ross: The tests that we use allow us to from pilots? do what we call age corrections; so age is removed as a Dr MacKenzie Ross: There have been anecdotal factor that could explain this. reports. In America and in Australia quite a large number of reports have come from cabin crew. In the UK most of the reports appear to be coming from Q140 Lord Sutherland of Houndwood: A comparison pilots at the moment but that may just reflect the fact has been made with Gulf War veterans’ illness, Gulf that we have not done a survey of other groups. There War syndrome as it is sometimes called and there was have been passengers on particular flights where there a US Research Advisory Committee on this that have been problems who have reported persistent ill suggested a probable link between such exposures to health following those flights. neurotoxins and the development of Gulf War syndrome. Do you see any value in looking at a Q144 Lord Sutherland of Houndwood: This is a comparison of this kind? slightly broader question and others may want to Dr MacKenzie Ross: Absolutely. I have come from come in on it, but are there practical preventative looking at farmers who report ill health and the reason measures that could be taken? the pilots identified me as someone to be referred to is Dr MacKenzie Ross: My understanding is that the because one of the components of engine oil is an technology exists already that could resolve the organophosphate and they felt that this might be the problem, if the problem is proven to exist. For relevant neurotoxin. Certainly the profile that I have example, filters are available that could be put on seen in the pilots is very similar to the profile of deficits aircraft. It is also possible to change the composition seen in farmers, so comparisons of this nature would of the engine oil and I believe there are engine oils be useful. It is also important to look at how the pilots available with a slightly diVerent composition. I am compare both with what we call healthy controls but slightly getting out of my area of expertise but I have also maybe with other pilots in the industry. At the been led to believe that that might be an avenue worth moment, my understanding is that certain aircraft pursuing. types appear to have more than usual numbers of fumeeventsandwhatwouldbeinterestingwouldbeto look at the profile of symptoms and deficits in pilots Q145 Lord Sutherland of Houndwood: You across diVerent aircraft types. mentioned earlier on monitoring the quality of air in the respective cabins. I do not know whether any member of the panel wants to comment on whether Q141 Lord Sutherland of Houndwood: You are that is being done or might be done more eYciently. specifying very interesting studies that might inform Professor Muir: We are about to undertake a major us. Is there a lot of research going on in this area? Is exercise where we will monitor continuously there any at all? throughout flights with the latest scientific equipment. 3844421006 Page Type [E] 30-11-07 13:08:07 Pag Table: LOENEW PPSysB Unit: PAG2

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One of the diYculties has been that until recently, amongst the medical profession about the health there was not the equipment available which would be eVects of flying and, frankly, I am not sure what else suYciently sensitive to do this. We now have new can be done. The Department for Transport is technology available and this will be brought into this updating its information, the Department of Health is study. We shall be using more than one type of updating its “Yellow Book”—health information for equipment. overseas travel, all the airline websites have Dr MacKenzie Ross: The slight limitation is that fume information, the Aerospace Medical Association events are quite hard to capture. You could in theory does, et cetera. We have sent posters to GPs’ surgeries. be monitoring aircraft and nothing happens. So It is diYcult to know what else can be done. obviously one issue is whether you capture a fume event or not. That is why some research needs to be done in parallel which is not dependent so much on Q148 Lord Howie of Troon: But do you think there monitoring; there ought to be some research just has been an improvement since our last report? looking at pilots/aircrew/passengers versus other Professor Bagshaw: The number of in-flight medical occupational groups versus healthy controls. incidents has not changed; that has remained Professor Bagshaw: When I was working for British constant. Airways, it came to our notice that one of our aircraft types appeared to be responsible for a high proportion Q149 Lord Howie of Troon: Do you think there of fume events and British Airways contracted with should be a comprehensive guide to GPs rather than BRE, an independent organisation, to come in to posters and things of that sort? monitor a series of flights. Nothing abnormal was detected on this particular aircraft type, although Professor Bagshaw: Yes, that information is available there were no fume events during the monitoring to them on websites. The Aerospace Medical programme. Just to answer your other question, if a Association has a very comprehensive guide, which is fume event occurs, there is a drill for the pilots to freely available to everybody. breath 100% oxygen immediately and the 100% oxygen then excludes ambient cabin air being Q150 Lord Howie of Troon: I want to turn to the breathed. It is of interest that in two fume events of question of personal freedom. Travel by air is a which I am aware, the pilots concerned reported that personal choice obviously but do you think people their symptoms got worse while they were breathing could be prevented from flying because of their the 100% oxygen, which makes one wonder about the existing medical conditions? relationship between the cause and eVect. Professor Bagshaw: That does happen. There is pre- flight medical screening but, going back to my original Q146 Lord Sutherland of Houndwood: Clearly cause point, you have to ask for it, you have to be aware of it. and eVect are the key issues. The major airlines will give advice. The check-in staV Professor Bagshaw: Yes. are trained to spot problems. If you turn up at check- in wheeling an oxygen cylinder it might be noticed, Q147 Lord Howie of Troon:There is a certain amount and certainly many airlines have the facility to get of information available to passengers and general medicaladviceatthecheck-in stageandthecabincrew practitioners on fitness to fly. How do you assess that? are conscious of assessing people’s fitness to fly by Is there enough information available? looking at them. If someone has a lot of spots or is Professor Bagshaw: There is a large amount of obviouslyshortofbreath, theymaywellquestiontheir information availablebut, as we hintedat before when fitness to fly. I do know that many airlines deny we were looking at risk factors with DVT, so much boardinganddenyflighttopeoplewhoappearunwell. depends on awareness and on self-declaration of health. Following the report of your Committee in 2000, British Airways sent posters and information to Q151 Lord Howie of Troon: My last query. Earlier on every general practice in the United Kingdom, so a we spoke about the problems of providing more poster was available to give information about the legroom for big people. Ican remember flying to Hong health risks of flying. Many airlines developed their Kong in the company of an international rugby player websites. I am not here representing British Airways I who was very large indeed; a Scotsman as it happens. hasten to add, but in my time at British Airways we Could something be done like providing two seats developed our health information on the website without actually charging for two seats? categorised into pre-flight, during flight and post- Professor Muir: The airlines would find that very flight; but you can lead a horse to water, but cannot diYcult because the airline that did that would be at a make it drink. My experience with lecturing to general competitive disadvantage to other airlines that did not practitioners is that there is an amazing ignorance operate the same policy. 3844421006 Page Type [O] 30-11-07 13:08:07 Pag Table: LOENEW PPSysB Unit: PAG2

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Q152 Lord Howie of Troon: Yes, they might be at a not and whether it is safe to open the exit. That is competitive disadvantage but they would be something cabin crew find diYcult to do with training. providing customer service which should matter to Professor Bagshaw: It is interesting that you cannot some. pre-select an emergency exit seat if you check-in Professor Muir: The problem is that many people do online, for that very reason. I would agree with not wish to pay for customer service. You can have Professor Muir that it is a very tricky situation. customer service in business and in first class but one of the lessons we have all learned from the low-cost Q156 Chairman: In summary, Professor Muir, you airlines is that if it is cheap enough we do not mind would not think it reasonable to charge particularly having nothing to eat, nothing to drink and will stay tall people more for added legroom? there for a very long time. We do not even mind not Professor Muir: That is not a question I can answer. having a pre-booked seat. It is becoming apparent to That would have to be a decision made by an airline. It the whole industry that price is the determining factor would be company policy. in passenger choice. Q157 Chairman: Could I return to the guide that GPs Q153 Lord Howie of Troon: I must say I do not really have and ask you, Dr ToV, whether all the diVerent like paying for my drinks. specialties, the cardiologists and orthopaedic and Professor Muir: I do not think anybody does. psychiatric experts,have beenconsulted onthis guide? Dr Toff: I suspect Professor Bagshaw is better equippedto answerthatbut Ibelieve itislikely thatthe Q154 Chairman: There is in fact at least one US specialist organisations such as the Aerospace airline I know of where you can, for the payment of Medical Association will have taken expert advice in £55, get five inches more legroom and that is a good preparing their own guidelines. idea. Do you think it would be a good idea to recommend that airlines provide such a capability? Q158 Chairman: Do you want to comment Professor Professor Muir: One could recommend that airlines Bagshaw? explored the possibility. The diYculty would be Professor Bagshaw: The answer is yes. Certainly the predicting how many people on any one flight would Aerospace Medical Association took a year to revise want the extra legroom and therefore how to design its guidelines because they took advice from all the the passenger cabin. specialties. IATA, the International Air Transport Association, publishes similar guidelines and, again, Q155 Baroness Finlay of LlandaV: On the ordinary they have taken specialist advice, so I can reassure you flights, the emergency exit areas tend to have more on that. legroom. How do you ensure that you actually do have fit people sitting in those seats who could open Q159 Baroness Finlay of LlandaV: I slightly play the emergency exit if needed, versus those who just devil’s advocate. The general practitioner is trying to particularly would like a bit more space to stretch out, help patients assess risk and interpret risk and I do but actually do not have either the upper limb strength wonder whether it is almost inappropriate to be or the right personality to cope in an emergency aiming the filtering points at the GPs who are actually situation. also acting as the patients’ advocate. At the end of the Professor Muir: The check-in crew are trained to select day there are lifestyle choices. The GP does not help people to sit in those seats who they believe could be them select which beds they sleep on even though they suitable to open the exit, but I have to say it is a very have bad backs, does not help them select what type of diYcult call because even if someone looks big enough kitchen furniture they have despite disability, or to manage it, it is very diYcult to say whether they are whatever. I just wonder whether it is really extending mentally robust enough to cope in an emergency. the role of the GP beyond the role that they ought to They are, in addition, approached when they sit in have and imposing an unrealistic expectation that those seats by the cabin crew and asked whether they they could somehow be a gatekeeper on those who are prepared to open the exit in an emergency. I have have an illness of some sort or a risk of some sort. to say it is a big ask of someone to open one of those Actually, if they know that is their risk, then it is up to doors. Most of the public do not realise what is them to take it, if they want to. The problem is that physically involved and that they might be in the very people do not understand risk and they think that diYcult position of having to make the decision about somehow there should be zero risk and there is no such whether it is safe to open it. When the captain calls thing as zero risk. over the PA, “Undo your seat belts and get out” or Professor Bagshaw: Absolutely. It is fair to say that calls an evacuation, at that point those people have to there is no expectation that the GPs are acting as the look outside and assess whether there is a fire there or filter. It is giving the GPs the information to allow 3844421006 Page Type [E] 30-11-07 13:08:07 Pag Table: LOENEW PPSysB Unit: PAG2

38 air travel and health: evidence

10 July 2007 Professor Michael Bagshaw, Dr Sarah MacKenzie Ross, Professor Helen Muir and Dr William Toff them to advise the patients who can then make their Professor Bagshaw: No, I have no recommendation. choice. If we go a stage further, most of the airlines do provide some form of medical filter, whether they Q165 Lord Sutherland of Houndwood: At the time of employ medical advisers direct or whether they the SARS outbreak in Hong Kong, when you went subscribe to a provider such as MedAire or through Hong Kong Airport there were screening International SOS who can provide pre-flight devices as you walked in, I understand taking your clearance and pre-flight information. I was a GP for a temperature. short time and I know the problem and I can reassure Professor Bagshaw: That is correct. you that there is no expectation that the GPs make the Chairman: They were still there last Tuesday when I decision. flew into Hong Kong.

Q160 Baroness Platt of Writtle: In the event of an Q166 Lord Sutherland of Houndwood: Are they outbreak of a major disease like pandemic flu, air helpful, minimally or maximally? travel would or could be the first crucial vector in the Professor Bagshaw: I believe they are of minimal spread of the disease. Can anything be done to benefit because there are many causes for a raised mitigate that eVect? temperature and in the early parts of the prodrome Professor Bagshaw: The World Health Organisation, your temperature may not be raised anyway. It is a the International Civil Aviation Organisation and the little bit of being seen to do something. International Air Transport Association have in place a series of protocols and procedures which have been Q167 Chairman: Surely, it could not do any harm to tested and have been audited in the Far East. Frankly, pull in people with a high temperature and just check we will only know if it works when the epidemic or the what the reason was. pandemic happens but procedures are in place and it is Professor Bagshaw: No, it would do no harm but there a well-recognised risk. We can never take risk out is no guarantee that they indeed have any infectious completely, and this is a high risk area, but the process going on. Picking up on your point, to see industry and the international organisations are what is causing the temperature is very diYcult in an cognizant of that risk. airport situation.

Q161 Baroness Platt of Writtle: Has any research Q168 Lord Howie of Troon: I was in an aeroplane on been carried out on how air travel is a vector in the Sunday coming back from Budapest and a lady, who spread of disease generally? was quite clearly afraid of flying, was conducted Professor Bagshaw: Yes. The World Health aboard by a stewardess. Is there much of that Organisation in association with ICAO and IATA particular problem? have looked at this. I am afraid I have not come Professor Muir: To get hard evidence is very diYcult, prepared with the data, but there has been work. but there are undoubtedly people who fly when they are extremely anxious about it. There are courses which they can attend. I also understand—I am Q162 Baroness Platt of Writtle: It would be a good 1 nervous with all the doctors here—that if you go to idea perhaps to let us know, if you do know the data, your GP, you can be given medication to reduce because that would help us. anxiety before you fly, but the cabin crew are also Professor Bagshaw: Yes. trained to help passengers when they experience these diYculties. Q163 Baroness Platt of Writtle: In your opinion, are screening procedures at the airports robust enough? Q169 Lord Howie of Troon: I think they were keeping Professor Bagshaw: No, frankly. Putting a an eye on this particular lady. thermometer in somebody’s ear is not very helpful. Professor Muir: They would do; certainly. You rely very much on the appearance, the personal screening and it is back to personal declaration, Q170 Chairman:Justbeforefinishing,mayIreturnto somebody saying “I feel unwell; I don’t feel fit to fly”. you Professor Bagshaw? With the pilots who If you have good reason to fly, you are not going to experienced a fume event and then followed admit to having a problem. Frankly, I do not see an instructions and breathed 100% pure oxygen, what easy answer. were the types of symptoms that continued then and what are the major first symptoms, other than an Q164 Baroness Platt of Writtle: Do you not have a unpleasant smell? recommendation? Professor Bagshaw: The symptoms reported are 1 tingling in the extremities, dimming of vision, slight diseases in commercial aircraft cabins. headache, inability to think clearly and a sense of Summary of recent research papers on transmission of infectious 3844421006 Page Type [O] 30-11-07 13:08:07 Pag Table: LOENEW PPSysB Unit: PAG2

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10 July 2007 Professor Michael Bagshaw, Dr Sarah MacKenzie Ross, Professor Helen Muir and Dr William Toff anxiety. The cognitive processes, the tingling of the they were able to put on oxygen and they recovered fingers, the dimming of vision, are all well reported and they managed to get control of the aircraft again. and they occur in a number of medical conditions. The kind of stories that have been reported are really Dr MacKenzie Ross: Some of the symptoms are what quite alarming and a lot more research needs to be we call non-specific and occur in many medical done to look at this issue further. conditionslike headacheand feelingtired. Someof the symptoms, things like eye, nose and throat irritation, Q172 Lord Colwyn: How long does a fume event are actually more indicative of an environmental normally go on for? You do not want to be breathing irritant being present, so there is a mixture of oxygen too long either. symptoms. The pilots that I saw reported that, if there Dr MacKenzie Ross: No. The oxygen does not last that was a major fume event, they might have these long, so you have an issue there as to how long it will symptoms and it would also include cognitive last. Depending on the aircraft type, my impairment. Some pilots were cognitively impaired understanding is the BAe146 pilots report that it can and unwell and lacked insight and had to have their smell almost continuously throughout flight, but that diYculties pointed out by the co-pilot. So people are when they fire the engine up, they often perform a not always aware that they are under-functioning and procedure called a pack burn where they try to burn this is something that really is of great concern. Also, oV the smell by increasing the heat, but that in itself some pilots say that although they are aware of a smell can produce fumes. With the 757, the fumes on board an aircraft, they habituate to the smell and apparently vary according to the stage of flight; they after a while they are no longer able to tell whether it is are worse on take-oV and landing and seem to present or not and they may be unaware of any dissipate during flight. We do not really understand impairmentthathasfallenuponthem.Forthatreason enough about what comes in, how long it hangs alone relying on pilots to be able to tell whether or not around, what level it is coming in and how it aVects a fume event has occurred and whether or not they are people and that is what we need to investigate further. impaired is less than ideal. Q173 Baroness Finlay of LlandaV: May I just ask you Q171 Baroness Platt of Writtle: It is dangerous. about the 100% oxygen? What are the cardiovascular Dr MacKenzie Ross: Yes; exactly. There should be eVects of breathing 100% oxygen for a length of time? some sort of objective monitoring which would When you say it does not last long, over what indicate whether there is a problem or not. I had one timeframe is the oxygen store there for the pilots? pilot who was in a very famous fume event where the Professor Bagshaw: They are breathing 100% oxygen plane literally nearly crashed and he said the problem for 15 to 20 minutes. It is of interest that the United was that he was so incapacitated he could not even States Navy pilots breathe 100% oxygen all the time. raise his arm to pull the oxygen mask down and he was That is their normal gaseous breathing supply and actually slumped over the controls staring at the there is no evidence of harm to the US Navy pilots. ground thinking “I’m going to die”. He now has post- Chairman: We have run out of time. Thank you very traumatic stress disorder as a result of the strength of much for your evidence. We appreciate the fact that belief he had that he would not be able to recover or you have come to speak to us and the time you have help himself by putting on oxygen. Luckily someone given us. Please, if you think of anything else that we else did manage to assist him; his co-pilot was not need to know, do let us know. Thank you very much incapacitated to the same degree at the same time and indeed.

Memorandum by the British Airline Pilot’s Association (BALPA) One of the main areas that have given concern over the last few years is that of the air quality in the cabin environment of aircraft. Technological problems combined with the diYculty of obtaining suYcient airframes, meant that to run a meaningful investigation was fraught with diYculties. Very little progress had been accomplished in this area, until recently. BALPA are proud to be part of the coalition that has formed consisting of airframe, and engine manufactures, airlines, oil companies, the regulatory authorities and of course us, the professionals exposed to the “risk” that has formed to investigate this issue. It is our belief that never before in aviation, anywhere in the world, has such a diverse coalition formed to investigate an issue. It is BALPA’s belief that this investigation which has been set up to be of unimpeachable scientific rigour, is leading the world into the investigation of possible cabin air toxicity. The equipment has been flight tested and it is anticipated that the programe will commence in full shortly. 3844421007 Page Type [E] 30-11-07 13:08:07 Pag Table: LOENEW PPSysB Unit: PAG2

40 air travel and health: evidence

BALPA is mindful that whilst pilots appear to be getting sick we must not assume that it is of any one causal factor. Pilots work patterns are extremely disruptive and undoubtedly cause deep fatigue in many. BALPA would deeply like a coalition similar to the one on cabin air quality to be set up to investigate the issue of fatigue.

It is BALPA’s view that the Aviation Health Working Group has been a useful forum now that a co-operative working relationship has been established. In the last year we have had most useful presentations on amongst other topics, disinsection and disinfection of aircraft, heart attacks and defibrillation, toilets, and various other physiological problems that aviation has to deal with. We have even had a presentation from Pall Industries the maker of aircraft filters. Research trips have been organised to organisations like BRE who lead the field into research into the cabin environment. Whilst it is our view little progress has been made into the deliverance of a better cabin environment, the research into producing a better cabin environment is underway, that deliverance of the better environment will follow over the next few years.

The Government, by helping to create an environment where the diVerent stakeholders have been able to meet and work together, has enabled an environment to flourish that has benefitted all, However, it is the realisation of the individuals on AHWG that there is a better way that has enabled the AHWG to make real progress.

It is BALPA’s view that this symbiotic relationship should be nurtured and enlarged and we disassociate ourselves from those who wish to indulge in a confrontational process. 18 June 2007

Memorandum by the Air Transport Users Council (AUC)

The Air Transport Users Council believes that the Committee’s report on Air Travel and Health, published in 2000, was a landmark document. It identified unresolved questions about aviation health issues on the basis of available information. It did much to put these issues into perspective and refute some of the misleading publicity surrounding the issue, and it set in train the allocation of responsibility in the UK for addressing aviation health issues to the Aviation Health Working group (AHWG) and the Aviation Health Unit (AHU).

The AHWG has facilitated a coherent approach on aviation health issues amongst the relevant UK organisations and industry representatives. It has been supported by the AHU, which has provided informed advice to the AHWG, the public, airline crew and the media, through its research into various aviation health issues.

The 2000 report recommended that the AUC refine its advice on health issues in its booklet Flight Plan to make it more specific than advising passengers to talk to their doctors about health issues. The Department for Transport requested that the AUC include the Department of Health (DH)’s advice on deep vein thrombosis in Flight Plan. The AUC added the DH’s advice when the new edition of the booklet was published in April 2002. The AUC has subsequently discontinued Flight Plan and moved all its advice to its website, including the DH’s advice on Deep Vein Thrombosis (DVT).

In the period since publication of the report, the Internet has transformed the way that information is supplied to consumers. It has made it easier for many organisations to set out to oVer advice, but it has led to a proliferation of unauthenticated consumer advice on many issues on many diVerent websites, much of which is often taken directly from other sources. This can be inaccurate and often is not updated as and when the source material is updated.

It is therefore important that advice on the health of air passengers comes from a specialist body. The AUC’s preferred approach is to oVer detailed advice on its area of expertise, such as flight delays or mishandled baggage. With more specialist advice, such as health issues, it provides links to the websites of other organisations. The AUC has removed the DH’s advice on DVT from its website and provides a link to the relevant pages on the AHU and DH’s websites. This ensures that the advice on aviation health on the AUC website is accurate and up to date.

We note that the Call for Evidence refers to measures taken to address new health concerns such as SARS and pandemic influenza. The aviation industry can indeed be a factor in spreading such diseases. But the AUC considers that these are general public health issues and not limited to the aviation community 14 June 2007 3844421009 Page Type [O] 30-11-07 13:08:07 Pag Table: LOENEW PPSysB Unit: PAG2

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Memorandum by the Independent Pilots Association

BriefDescription of theAssociation The IPA is a professional association of UK based pilots. It has a membership of approximately 1,500 drawn from all sections of aviation, from students to 747 senior captains, from new entrants to Flight Operations Directors and was established in 1991 as an alternative to the British Airline Pilots Association. It is run and operated by current and retired professionals from within the aviation industry and has a wide area of aviation expertise upon which to draw, having amongst its membership flight crew members with Doctorates, a Professorship and Chartered Engineers. The IPA is currently giving attention (in addition to many other non-health issues) to DVT, radiation exposure, carriage of potable water on freighter aircraft and cabin air quality. The Association actively participates in both national and international consultative forums (eg flight safety, engineering, aviation security, health and human factors) to facilitate the exchange of information that will enable its members to execute their duties to the highest professional standards. Helping keep British aviation at the forefront of best practice and the model to be emulated by others is of prime concern to the Association as, no doubt, it is to the Committee.

Concerning the Committee’s Recommendations in the Fifth Report into Air Travel and Health, Summary and Recommendations

Concerning recommendation 1.9: Actively pursue internationally crew and passenger health interests The Association wrote to the Chairman of the CAA expressing its concerns regarding the potential eVects on crew and passenger health from cabin air contamination events linked to engine lubricating oil leaking into aircraft cabin air supply systems. The Association was told to bring the matter up with EASA themselves.

Concerning recommendation 1.11: Monitoring and recording of the general health of aircrew The Association currently has nine members undergoing medical investigations due to problems they have reason to believe, emanate from cabin air contamination linked to engine oil leaks. Despite advising the DfT of the requirement for a medical protocol to thoroughly investigate the problem some time ago, the problem being known of for many years, the matter is still being discussed and researched. The Association is left wondering how many more pilots must lose their jobs and livelihoods before the problem is accepted and resolved. Similarly, no consideration is being given to the eVect on human performance that the cocktail of known chemicals emanating from heated, vaporised aircraft engine lubricating oil leaking into an aircraft’s air- conditioning system. Or the believed marked increase in toxicity of the chemicals under such conditions.

Concerning recommendation 1.12: Exchange of medical information between a crew member’s AME and General Practitioner Members of the Association have no evidence this occurring.

Concerning recommendation 1.13-15: Health Guides No advice given, in any publication, regarding what passengers should do if they are taken ill on a flight because of something that is believed to have happened on that flight.

ACase inPoint A group of unrelated passengers (approximately 40), on the same flight, became ill with similar symptoms, on a flight to the USA, all stayed at diVerent locations, most required medical attention, some hospitalisation, none received a definitive diagnosis. Some still suVering reduced symptoms months later. The airline concerned states to concerned passengers that no-one else has complained. A group of the passengers are in contact with each other and know this to be wholly untrue. As far as the passengers are concerned the airline 3844421009 Page Type [E] 30-11-07 13:08:07 Pag Table: LOENEW PPSysB Unit: PAG2

42 air travel and health: evidence is in denial and very little if anything has been done to address their concerns let alone discover what they were/ are suVering from. The Association believes a full account is being provided to the Committee by a group of those passengers aVected.

Concerning recommendation 1.24: Ventilation The JAA requirement states: “Each crew compartment must have enough fresh air . . . to enable crew members to perform their duties without undue discomfort or fatigue” and; “Crew and passenger compartment air must be free from harmful or hazardous concentrations of gases or vapours.”

Concerning recommendation 1.25: Air Quality The current continuously monitored basic cabin environment data only includes, cabin air temperature and pressure, and bleed air temperature and pressure, not what is in that air.

Concerning recommendation 1.26: Air Quality The Aviation Health Working Group is addressing the sampling programme, however it is neither simple nor inexpensive and considering the Committee’s recommendations were published in 2000 is progressing very slowly. Yet to be defined is what the samplers are to be designed to detect and at what levels. Research is in hand to address this deficit. Another unknown is what eVect the cocktail of chemicals known to emanate from pyrolised aircraft engine oil that leaks into an aircraft’s air-conditioning system has on the human body. The Association believes this point has been overlooked by the AHWG as no reference to required further research in this aspect can be found. The Association has reason to believe that the level of toxicity of some of the constituents in aircraft engine lubricating oils greatly increases when it becomes pyrolized i.e. changes from a fluid to a heated and vaporised state. From the little research on the subject that has been located it would appear that further in-depth research is required. Both the DfT’s Aviation Health Working Group and the CAA’s Occupational Health and Safety Steering Group would appear to be selective and non-inclusive in the selection of representatives they choose to have in their groups. The IPA has been denied representation on both groups despite its diverse range of aviation expertise.

Concerning Recommendation 1.43(c): Research Covered above.

Concerning Recommendation 1.43(f): Research The Association can find no aspect of this in the public record and has no evidence from members that is happening.

Concerning Recommendation 1.47: Complaints Procedure Covered above. 18 June 2006 3844421010 Page Type [O] 30-11-07 13:08:07 Pag Table: LOENEW PPSysB Unit: PAG2

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Examination of Witnesses Witnesses:CaptainTimBamber, NEC Member, British Airline Pilots Association (BALPA),MrSimon Evans, Chief Executive, Air Transport Users Council (AUC) andMrPeterJackson, Director, Independent Pilots Association (IPA), examined.

Q174 Chairman: Welcome Captain Bamber, Mr Mr Jackson: The report is available from COT. Evans and Mr Jackson. Thank you very much for Basically, both pilots became severely incapacitated coming to give us evidence. You will have seen how and nearly crashed the aeroplane. The subsequent we proceed as you have been here already. Would report by the Swedish Government hinted at the you please introduce yourselves and make an possibility of the contaminated air eVect being opening statement, if you so wish? responsible for the incident. Honeywell subsequently Captain Bamber: I am Tim Bamber. I am a medically obtained the aVected engine and did tests on it, I retired captain from My Travel Airways and I share believe a full spectroscopic analysis test on it in a the distinction, along with Lord Colwyn, of being a ground test rig, and that is where the results came retired dentist. from.

Q175 Chairman: An interesting combination. Q178 Baroness Platt of Writtle: You were saying it Mr Evans: I am Simon Evans, Chief Executive at the would be better to put sensors in the aircraft, but on Air Transport Users Council. My organisation has the other hand you then talked about 54 constituents. submitted a small memorandum and I do not have That is going to be rather a diYcult job, is it not? anything else I would like to say by way of Mr Jackson: It would be a diYcult job, hence the introduction, thank you. suggestion that the best way forward would be to do Mr Jackson: Peter Jackson, one of the directors of the the ground tests first to find out what the constituents Independent Pilots Association. My special are and in what concentrations. Then the aircraft responsibility is aircraft engineering and aviation sensors can be programmed to look for those specific security. I have been in aviation for 48 years as an things. It would make the job a lot easier. The other engineer and flight engineer and the only statement is fact is, of course, that we do not know what the that we have lots of members with this problem, combined eVects of the 54 constituents are and as far please help us to fix it. as we have been able to ascertain nobody has mooted any research to be commissioned. Q176 Chairman: How eVective, in your experience, has the Aviation Health Working Group been in Q179 Chairman: Mr Evans, Captain Bamber, would taking forward the recommendations of our you like to comment on this first question? original inquiry? Mr Evans: I should like to take a diVerent view. My Mr Jackson: Slow. Bearing in mind your Lordships’ organisation has been very comfortable with the way recommendations came out in 2000 and the Aviation the Aviation Health Working Group has taken Health Working Group has only been eVective for forward the recommendations from your Lordships’ the last two years, a lot of time has been wasted. May previous report and it has given us great comfort that I refer to the notes I made to answer your questions? there is a forum comprising representation from As an association we envisage there are still Government, from industry and from the Civil shortcomings in what the COT are proposing with Aviation Authority which will not necessarily take a regard to the type of tests they are doing. To take air view on an issue but take a view as to whether an issue from an aeroplane as a sample and back to the needs further investigation. This has been involved in laboratory for testing to find out the basic discussions on considering whether it should be taken constituents is wrong. You can do it quite easily on forward, how it should be taken forward and, in a ground test rig; the equipment is available; you can particular, we have taken great comfort from the access a mass spectrometer and test in real time. Once setting up of the Aviation Health Unit within the you have decided what the constituents are, and we Civil Aviation Authority, which does provide a have a good idea from the report into the repository for information and for people to know Scandinavian aircraft incident, you can then that there is an organisation taking care of concerns programme specific sensors to look for what is then about health in aviation that were not being taken known to exist. The other consideration we are account of previously. concerned about as an association is that no real Captain Bamber: I concur entirely with what my consideration is being given to the eVect of the colleague on my left here, Mr Evans, has said. It cocktail that is in the air. From the Scandinavian might have been slow oV the ground; the Aviation incident we have identified 54 possible constituents. Health Working Group did not hit the ground running, but in the last couple of years it has started Q177 Chairman: Can you describe that incident to working extremely well together. It is a forum where us a bit please? all sectors of the aviation community come together 3844421010 Page Type [E] 30-11-07 13:08:07 Pag Table: LOENEW PPSysB Unit: PAG2

44 air travel and health: evidence

10 July 2007 Captain Tim Bamber, Mr Simon Evans and Mr Peter Jackson and we are now working as one to try to investigate further. It is like a pyramid: you start with a broad problems. As far as the last House of Lord’s inquiry base and work up to a narrow spectrum. We cannot is concerned, we actually brought up the issue of put the sophisticated sensor on. The one we have at cabin air quality and said that progress was slow and the moment or possibly the one we will be using will it remained slow until recently when COT got going monitor for six substances. It monitors, which is and the Aviation Health Working Group took a essential, on a real-time basis. Of the initial monitors, handle on it. We also brought up air crew health, one of them will only tell you whether an event has which I believe Simon Evans has actually now got a occurred and the other one gives you a bit more data. handle on as well. Those are positive results that It is essential that we have a real time on this, because came out of the last Lords’ inquiry. As far as the COT it could be that these cabin air events are being caused committee is concerned, I have given evidence to it, I by the APU, the auxiliary power unit, that is the little have attended all the briefings and hearings and I motor that fires up the electrics and things on the have read all the reports, most of which are here, ground. It could be you are sucking in another including annex 11 which is the Honeywell data from airframe’s exhaust fumes when you are taxiing and the Scandinavian case. If you would like it, I can leave you could solve it by just moving further back. It that with you. Throughout the COT report it does could be—my favourite theory—that it is when you frequently refer to lack of data, dearth of close the throttles at the top of the descent. The information: lack of data is paragraphs 32 to 34; curious thing is that the aeroplanes that are most paragraph 42 on air exposure monitoring talks about susceptible, the 146 and the 757, are principally being dearth of information. It is essential in this inquiry used on short-haul routes and in short-haul that, first of all, we find out what is being produced. aeroplane flying you climb the aeroplane to altitude, The epidemiologist and the statistician said that to be you close the throttles and you descend again. The sure of monitoring one full-blown cabin air quality 146 does not have a cruise phase or, if it does, it lasts event you have to monitor 3,000 flights, 3,000 sectors, minutes. We have not had large numbers of these which is a heck of a number of sectors. We have incidents, if any, in things like the 747 which do long chosen to monitor the 146 and the 757, because they range, where your engines are treated more fairly. In are the aircraft in which these events have been most the 146 and 757 it is a pretty grim life for an engine: widely reported. The initial tests of the 146 have gone full power; climb power; close throttles; descend. well. We are having scheduled tests later on this month in the 757 and we anticipate we start getting Q180 Earl of Selborne: On this monitoring that real data back from these tests by the end of Captain Bamber is referring to, you raised this five September. As my colleague Mr Jackson from the years ago at the previous report. Are you satisfied IPA said, a huge number of volatile organic that in the last five years enough eVort has been put compounds occur. Honeywell noted something over in by all parties, including the AHWG, which of 90 and there were other tests done which again spoke course did not exist then, in order to set these trials up of in the region of 90 chemicals being produced. It is which you explained so clearly are what is required? impossible to monitor each of these in real time, so we Captain Bamber: I cannot answer that fully because I are using two diVerent sensors on two diVerent types was not on the Aviation Health Working Group five of aircraft that basically will indicate whether a cabin years ago. However, since I joined the Aviation air event has occurred and what has occurred in it. Health Working Group, it has moved at speed that is This you might term as a screening process, because really ahead of the information that is coming we want to try to find out which aeroplanes, out of forward. The Aviation Health Working Group has the 146s and the 757s that we are monitoring, are anticipated what COT would recommend, has gone prone to these cabin air quality events. Then we can out and tried to locate the sensors, locate things so put the more sophisticated instruments on these that when the COT committee recommends, it is in a aeroplanes which will monitor in real time but will position to implement the recommendations. The only monitor a selected number of semi-volatile committee could not have done more, faster; I speak organic compounds. We have to get a handle on what over the last two years though, I do not speak about is being produced in these cabin air events, how the previous time when I gather there were log jams. frequently they occur, then we can move on to the I am proud to be a member of what has been a second stage. As Mr Jackson so correctly said, it committee that has actually done a lot of good for might not be a compound, it may be a couple of aviation and has brought together a coalition of oil compounds and we are not closing our minds, just companies, engine manufacturers, airframe saying it is organophosphates or it is something else. manufacturers, the regulatory authorities, both the We are saying a large number of compounds, Civil Aviation Authority and the medical department somewhere in the region of 90, are being produced, of the DfT and trade unions all working together. It is we must find out what they are, we must find out the very delicate. We have two airlines participating. One quantities of them and then we can target in on it airline is non-BALPA but is participating with the 3844421010 Page Type [O] 30-11-07 13:08:07 Pag Table: LOENEW PPSysB Unit: PAG2

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10 July 2007 Captain Tim Bamber, Mr Simon Evans and Mr Peter Jackson inquiry; the other airline is a foreign airline. We have Captain Bamber: That will give us a handle on it these things, but it is a very delicate situation. We can otherwise we are fishing in the dark. That is my be proud of it and it is a forum which ought to move theory. I have no evidence for it. I am just saying it is ahead and start inquiring into other issues which are coincidence that the aeroplanes which seem to have pertinent to aviation in the same bipartisan approach the greatest problem are those which are used almost as we have done with cabin air quality. exclusively on short-haul flying because the general theory is it is a leaking seal and these seals heat up and cool down. Q181 Earl of Selborne: In the previous evidence, which you may have heard—I am not sure whether you were present when they were giving evidence— Q184 Lord Sutherland of Houndwood: What I liked they also suggested that as well as monitoring, about your theory was that immediately there was a further research needed to be done on the testable hypothesis; you could look at other aircraft composition of engine oil and on the nature and with short flights. construction of filters. Would you like to comment Captain Bamber: We intend to eventually. At the on that? moment though we are looking at monitoring Captain Bamber: First of all we need to know what is something in the region of 40 aeroplanes. being produced and why it is being produced. There is no point whatsoever in having a filter if there is Q185 Lord Haskel: We have learned about the nothing to filter out or if you can cure the cabin air health concerns of the crew. Have any members of quality events. We need to have the data coming the public reported any new health concerns since our forward which will come forward rapidly. We had a report in 2000? talk in the Aviation Health Working Group from Captain Bamber: The public are obviously concerned Pall Industries, who are manufacturers of the with things like SARS and also they have become far principal filter. They say they can make a filter to more aware of what you might term the risks filter out anything, but they need to know what needs associated with air travel. Part of the risk is going to to be filtered out because if you filter out everything, places like Bombay and your risk is not that you have you are left with nothing. They have to know what to flown to Bombay; it is that you are in Bombay. There produce a filter for. The first stage of the inquiry has is a greater awareness of health risks associated with to be done before you can move on to the next stage. air travel, yes. Likewise with the composition of oils. Is it our job to Mr Evans: Sometimes we assume that people are tell an oil company how to make an oil? Is it our job taking a closer interest in potential health risks of air to say that something is being produced in the oil travel; than may be the case simply from what we which is harming our pilots and they should go away read in the media. I was grateful for being forewarned and fix it? We take the first view, that we find out what of this question because I actually looked at our is causing harm and if it is an oil related problem, we database in the AUC. I can tell you that since 1 say to the oil companies that this appears to be giving January 2001, out of a total of over 32,000 telephone a problem, please fix it. I am very reluctant to have enquiries, we recorded 94 under the heading “medical”. They would include people who wanted civil servants and pilots tell an oil company how to to know whether they could fly after 32 weeks of make an oil. pregnancy, for example, people who were worried about peanut allergies and wanted to have peanuts Q182 Lord Sutherland of Houndwood: You banned from airports and people who just felt unwell suggested that perhaps one of the options to look at after flying or had had a cold. I did not notice carefully was the length of actual cruise at the top of anything new there; anything that any your the flight; the climb and then the descent were critical Lordships around the table would consider to be factors in your own thoughts. Does that not suggest new. Out of a total of 20,000 written complaints we that rather than looking at particular types of had 58 that we categorised as medical. I feel more aircraft, we should be looking at short air flights with comfortable talking about the written complaints a very short cruising period at the top? This could because these are complaints where we have actually apply to 747s. I can remember taking a 747 seen some documentation and something in writing Manchester to Schipol before going on to the Far rather than a telephone enquiry. Running through East. Is that an option? the list of things that came out of those 58: pregnancy Captain Bamber: We ought to wait to see what the was an issue that came up several times; injury, data produces first of all. people who had been injured, typically skiing, and were being told they could not fly for a number of reasons; allergies, peanut allergy is a fairly common Q183 Lord Sutherland of Houndwood: On these one; it was too hot or it was too cold on board. Of specific aircraft. those 58 in the six years only two were, for example, 3844421010 Page Type [E] 30-11-07 13:08:07 Pag Table: LOENEW PPSysB Unit: PAG2

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10 July 2007 Captain Tim Bamber, Mr Simon Evans and Mr Peter Jackson from people who were concerned about DVT. have been less reluctant to use the expression. They Inasmuch as I know what the issues are, paging do alert people to the possible risk of DVT if they through those 58 or the 94 telephone enquiries I did have certain predisposing factors and so on. not spot anything that struck me as new. Generally it seems to be there, the information is there, passengers’ attention is drawn to it. The media Q186 Lord Haskel: Do we conclude from that that have done very well in calming down over the last few the pre-flight and the in-flight information available years and you see a lot more intelligent, well- to passengers is perfectly satisfactory? researched articles in the travel pages across all the Mr Evans: I would be reluctant to conclude that. I am media, not just the quality media, with tips that a little bit unsure as to what pre-flight information we people can take just to make their travelling more should be giving people. I suggest that the concern comfortable across the board not specific to should be that we are looking at whether there is particular health issues. anything specific to air transport as a potential health issue against which perhaps we should be warning Q188 Baroness Platt of Writtle: Have crew members people. If we have not identified anything there, it is or pilots reported any new health concerns since diYcult to understand precisely what information we 2000? should be giving them about air travel specifically. I Mr Jackson: Yes; fatigue. It is a factor going back to am sure that people who have existing medical low-cost airlines and low-cost inclusive tour conditions are coping with those conditions companies. Their nature of operation is that they throughout their daily life, so they probably know want to turn the aeroplanes around fairly quickly. about it better than any of us who would purport to Even though the Civil Aviation Authority in CAP371 give them information on an inexpert website. They laid down guidance on how pilots must be rostered will consult their doctors if they think they need to, and the maximum hours they can operate, the airlines if they are doing something that they have not done are tending to use CAP371 as the maximum and they before or which has caused them concern. Beyond ensure they get the maximum out of their pilots. This that the main issue that we need to warn people about is obviously due to commercial pressures, but it is is that they need to make sure that the airline is having an eVect on the pilots. There are two airlines comfortable with and prepared to accept them for which have tended to address the problem by putting travel with their particular condition. That is very fixed working times in; six days on and three days oV much in the passengers’ interest so that in rare in a fixed working pattern. Unfortunately, whilst it circumstances they may be denied carriage but also, seems very good in principle, the pilots tend to find if they need specific provision to be made for them by that their last working day prior to their days-oV is the airline by forewarning the airline, there is a better eroded by arriving back very late at night. On the chance that the airline will be able to give it to them. start of the flying programme their first flight is I suppose in a convoluted way I have answered yes to always very early, so it eats into the preceding day your question. inasmuch as they have to go to bed early to prepare for it. This, linked with landing back when they come back into England into a diVerent airfield, they have Q187 Lord Haskel: What about during the flight? to position back by taxi to their home base before We have been told that it is a good idea to get up and they can drive home, cuts into the time they can have walk around and everything. Do you feel that for rest. In some cases, they do not even have taxis, adequate information is given to passengers about they have self-drive cars provided. This adds to the that and about the possible health hazards during stress and reduces the rest time unfortunately. the flight? Mr Evans: I am sure previous speakers before this Committee have alluded to potential practical Q189 Baroness Platt of Writtle: What are the diYculties of people walking around aircraft. Yes, I implications of ultra-long-haul flights on pilots’ and would say that is one area where, following your crews’ health? report in 2000, airlines have been much more Mr Jackson: As an association we have no adverse proactive in drawing their passengers’ attention to comment from our crews on this and from a personal information. In a number of carriers it was already point of view, having done it myself, long-haul flights there in their in-flight magazines and certainly when I are normally far better for the individual. have flown recently, there has often been a suggestion that passengers do flick to those pages in the in-flight Q190 Chairman: Captain Bamber, do you want to magazine and look at the health advice there. There is comment on that? a question of judgment to be made as to whether the Captain Bamber: I want to make brief comments on airline tells you precisely why they are giving you that what Mr Jackson said and what Mr Evans said. information. Since DVT had so much airing in the Basically I wholeheartedly agree with both of them. media and became such a high-profile issue, airlines There was one tiny thing that Mr Evans said about 3844421010 Page Type [O] 30-11-07 13:08:07 Pag Table: LOENEW PPSysB Unit: PAG2

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10 July 2007 Captain Tim Bamber, Mr Simon Evans and Mr Peter Jackson sick passengers. I personally—I am now putting ounce of work out of pilots. Within the same forward a personal view because the Association has legislation people are having to work harder because not really taken it up—feel that you should, as an of the computer generated programmes and, as Mr airline, treat very warily the idea of refusing Jackson said, things like slot one departures, which passengers travel. Basically I think it should be that are often airborne at half past six in the morning, all can travel unless there is some explicit overriding which realistically means report half past five, at the reason to refuse them travel. The reason I say this is airfield at five o’clock at the latest to get your from my days as a dentist and I hope Lord Colwyn transport to it, which means an hour’s drive for most will back me up on this. When AIDS first came out people, leave home at four o’clock, up at half past lots of dentists refused to take patients who were in three. It is not much of a day oV when you are getting an AIDS-risk category for treatment. So an AIDS- up at half past three. So things are eaten into from risk category patient went to the dentist with either end and the fatigue issue is a real issue. I looked toothache, he was refused treatment; he went to out some of the data on fatigue. There is a chap called another dentist and did not tell him he was in an Horne at Loughborough University who has done a AIDS-risk category group so received treatment. huge amount of research on fatigue and he reckons That meant the dental surgeon was treating him that a fatigued driver is as dangerous as a drunk probably without the full range of precautions that driver and in some of his articles he has actually gone he was able to take in other circumstances, if he knew through and found that something like 25% of all the true history of the patient. This will feed through accidents are now related to fatigue. It is a danger into flying. If somebody has to fly to get back to that we are putting our passengers in. As a pilot we England because they are pregnant and want to have can only fly an aeroplane with one quarter the their baby in England, they will say they are 28 weeks amount of alcohol that I can drive to the airport with instead of 36 weeks. So you will end up carrying a in my blood or drive home from the airport with in high-risk patient but assuming they are not a high my blood, but I have to have one quarter the amount risk. I just mention pregnancy, but it could be any one to fly an aeroplane. As far as fatigue is concerned, I of a number of things. I would rather carry a can work a 14-hour plus day at the controls of an passenger knowing they had a risk and knowing what aeroplane and that is alright. That strikes me as the risk was than carry the same passenger not crazy. Fatigue was an issue which I thought would be knowing he or she was a risk. I am very loath to go ideal for the Aviation Health Working Group to look down the route of denying people travel. That is my at in its bipartisan way. We are not after screwing the only slight disagreement with Mr Evans. As far as Mr airlines: we are after making sure that the public Jackson was concerned, where he spoke of new travel safely and that they all travel safely to the same things, I fully and wholeheartedly agree with what he playing field. Some airlines have scheduling said over fatigue. This is a huge issue facing the agreements and do not schedule their pilot to airlines at the present time. There are several reasons CAP371. Other airlines schedule their pilots to for this. I shall not go over the ones that Mr Jackson CAP371 and, in our view, they are taking a risk with mentioned but just add a few. One of them is the car the travelling public. parking. When I was based at Luton, I parked my car and in one minute’s time I was in my oYce. When I Q191 Lord Sutherland of Houndwood: May I just was transferred to Gatwick, it was a minimum of half press on that? This is clearly a very important issue in an hour from the car park to the oYce and at night your mind and indeed in ours. In view of what you and early mornings it could be three quarters of an have just said, would you be as clear as saying you hour or more. That extended my working day by an have reason to believe some airlines are putting hour and a half. When CAP371 was drawn up, passengers and/or crew at risk by their practices? which, I do not know whether you know, is the legal Captain Bamber: Without hesitation I would say that; maximum that pilots are allowed to work, it said in yes. I cannot see how we can have a pilot who has the prelude to it that the document was not meant to been at the controls that long a time not being a risk be used as a scheduling document, but was the to himself and to other road users driving home. maximum hours that a pilot could be worked in periods of short time and high workloads. Many Q192 Lord Sutherland of Houndwood: Is it the CAP companies have taken it as being the basis to which causing the problem or is it the add-ons? to crew to. They were not able to do this until fairly Captain Bamber: It is principally the add-ons. recently, because if you altered one person’s line of CAP371 was not written in today’s environment. The work, you had to re-alter every other pilot’s line of world has changed, the environment has changed work manually and that was so time consuming that and we need to have a re-look at the whole issue. it could not be done. With the modern computer Personally I think the Aviation Health Working generated programmes that can fit your programme Group, because it is a bipartisan body, is the in and programme all your pilots, they can get the last organisation which should look at that. 3844421010 Page Type [E] 30-11-07 13:08:07 Pag Table: LOENEW PPSysB Unit: PAG2

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Q193 Chairman: Have you put that to the group? Q201 Lord Colwyn: We heard earlier of the potential Has the group declined? crash because of the fume event. An automatic pilot Captain Bamber: No. is available, is it not, in a situation like that? Captain Bamber: But the automatic pilots have a Q194 Chairman: Are there data to show how many tendency to trip out and fail. hours a pilot flies now compared with the year 2000? Captain Bamber: Yes. Q202 Baroness Platt of Writtle: Anyway it was Mr Jackson: Yes. It is mandatory to keep all those coming in to land, was it not? records and they have to be available. Captain Bamber: Yes.

Q195 Chairman: So we could obtain those. Q203 Baroness Platt of Writtle: Going back to what Captain Bamber: Yes. you were saying, do you think low-cost flying is what is really causing these changes? Q196 Chairman: Your argument is that a major Mr Jackson: From the IPA’s point of view, yes. factor is that scheduling programmes has become Mr Evans: May I throw in a slight note of caution? Of more sophisticated and that is one of the main course as a consumer organisation we have, like all reasons why pilots fly longer. consumer organisations, safety as the number one Mr Jackson: Yes, they schedule pilots to fly to the priority. I just wonder whether pilots’ hours and maximum permissible time, not to the spirit of the fatigue are more issues for the safety regulator than CAP371 which was designed initially to prevent for an Aviation Health Working Group. Of course fatigue. fatigue is a health issue but I just wonder whether we should let is go as read that it would be an issue for the Aviation Health Working Group rather than for Q197 Lord Colwyn: Does the pilot’s job not become the safety regulators in the first instance. more and more an issue of just sitting there and Captain Bamber: It is primarily a role for the safety making sure that the computer is doing it properly? regulators, there is no doubt about it, but we have the Captain Bamber: You are an anaesthetist. When you Aviation Health Working Group, a bipartisan body, are an anaesthetist does your job involve sitting there which we do not have in the safety regulators. The and reading a book or is it 90% boredom followed by Aviation Health Working Group has worked so well 5% blind panic? in the last year or so that it seems to be an excellent Lord Colwyn: You have me there. forum in which contentious issues might be examined in a de-heated manner, so to speak; people can sit Q198 Lord Sutherland of Houndwood: I think we are around and look at it in a close environment. Is there asking you a question. a clear demarcation line between aviation health Captain Bamber: I chose to answer it in that way. We and safety? used to have a saying, a cold sweaty patient, hot sweaty dentist, which Lord Colwyn will know all Q204 Chairman: Do all of you agree that the about, as I do. The problem is that you have to be working group is ideally constituted and doing the alert for when the bells and whistles go oV. The optimum job that it can do? majority of the time it is sheer boredom but every two Mr Jackson: No, because we are not allowed to be or three months you earn every penny of a year’s on it. salary. Mr Evans: From my organisation’s perspective it may be in a position to look at organic change, if even Q199 Lord Sutherland of Houndwood: That is not in I know what I mean by “organic”. It was a group doubt but I really wanted to press you just a little which set out with a specific remit to look at aviation further on the extent to which the scheduling is the health issues and most of us understood what we cause. You are making a very serious charge. meant by “aviation health issues” at the time, which Captain Bamber: It is the scheduling combined with was to find out whether there was any data which the add-ons, the fact that you have to park your car. supported some of the claims being made about deep All airports are reserving the near space with their vein thrombosis, for example, whether there really expanding terminals and the thing which is being were any issues about cabin air quality which were moved away from the airport is the staV car parking causing health problems for passengers and flight arrangements. crew. Most of those issues have now been teased out and certainly the recommendations from your 2000 Q200 Lord Sutherland of Houndwood: I can assure report have been taken account of by the group. It you it is the same for passengers in many cases. may be that now the Aviation Health Working Captain Bamber: Passengers pay good money so they Group is in a position, not exactly of having get preference now. concluded its remit, but maybe where the priorities 3844421010 Page Type [O] 30-11-07 13:08:07 Pag Table: LOENEW PPSysB Unit: PAG2

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10 July 2007 Captain Tim Bamber, Mr Simon Evans and Mr Peter Jackson th may change. If the suggestion is that there is need for doing that and my wife used to enjoy coming on an an inclusive forum to consider health issues, then that occasional trip. I forgot my son’s 18 birthday and I would not necessarily be an extension of the remit of took him on a trip because I was not oV work for it. the Aviation Health Working Group but an That was banned by the regulatory authorities. alternative forum where those issues could be aired. They are being aired and I have an open mind as to Q210 Baroness Platt of Writtle: I am an aeronautical whether the suggestion is that there is a need for engineer and I have been invited into cockpits on a another forum for it. number of occasions. Captain Bamber: Since 11 September? Q205 Lord Haskel: The point which is being made is that the pilot is a danger after he has finished work, Q211 Baroness Platt of Writtle: No. when he is driving home, because of fatigue. Captain Bamber: We used to be able to invite people Captain Bamber: As well, yes. in; it was something we enjoyed doing. I heard the tail end of your evidence about a passenger who was Q206 Lord Haskel: Is the AHWG looking into that frightened of flying. One of the things we used to do aspect as well? with the passengers who were frightened of flying was Captain Bamber: Not as yet. I hope that it might be to take them into the cockpit and show them all the something that the Aviation Health Working Group safety features and show them the things we have. We would look into. Because we have a bipartisan, across cannot do that any more. It has diminished our the industry, functioning group, we ought to say enjoyment of the job, partly because we cannot “Hey, we’ve got this thing going. By all accounts it interact with the passengers as well. We might get took a while to get it going properly, but it is going, some engineer on the flight deck whom we do not it is working properly. Let’s be proud of it and let’s know, who is from another company. He is not a utilise it in other areas of aviation”. I do not accept security risk but apparently my wife might hit me that there is a clear division between health and over the head with an axe and she is a security risk. It safety; in my mind the two go together. It might be is something which has caused an enormous amount that it meets one month and it is called the Aviation of tension amongst pilots and the added security Health Working Group and another month it is measures which came in last August as well have called the Aviation Safety Working Group, with caused even more. A number of pilots have come very basically the same constituent parts. close to losing their jobs as a result of the measures.

Q207 Baroness Platt of Writtle: Security measures Q212 Earl of Selborne: I should like to go back to were put in place after 11 September including the fume events about which we have talked quite a bit locking of the cockpit in flight. Are pilots able to already. There is obviously agreement that fume move around and exercise suYciently to prevent events do happen, but some disagreement over the fatigue and even perhaps VTE? extent of the health implications for pilots and crew. Captain Bamber: You still need to perform the How widespread is the concern over fume events functions of nature, which means getting up and amongst pilots and crew? What advice do you give leaving the cockpit. your members when they contact you claiming to have suVered a fume event? Q208 Baroness Platt of Writtle: Do you unlock the Captain Bamber: The worry about fume events varies door then and lock it again? from airline to airline and aircraft type to aircraft Captain Bamber: You unlock the door and then a type. It is not universal across the profession. The 146 member of the cabin crew comes in to replace the pilots, because that has been one of the alleged rogue pilot. You go out and go to the loo and when you aeroplanes, are very concerned, as are some of the have finished you buzz through and the door is 757 pilots. It was a particular engine fit on the 757 unlocked and the two swap over again. which appeared to give the problems. There is a great deal of anxiety amongst them. Q209 Baroness Platt of Writtle: So that is okay. Captain Bamber: That is okay. Since you have Q213 Earl of Selborne: What advice do you give brought it up, I would say that the security measures your members? which have come in since 11 September are the Captain Bamber: At the present time our advice is, if biggest single bone of contention as far as pilots are they have suVered symptoms, that they should take a concerned. It is an incredible irritant. There are two full 12-hour rest before considering a return to duty. spare seats in most aeroplane cockpits and those seats If symptoms remain they should seek medical were the gift of the captain. It meant, for instance, if assistance. We are expecting that to change shortly, you were away from home for a week’s trip, that you because the COT committee did talk about blood could take your wife. I used to do that, I used to enjoy tests and biomarkers, in paragraph 71, if anyone 3844421010 Page Type [E] 30-11-07 13:08:07 Pag Table: LOENEW PPSysB Unit: PAG2

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10 July 2007 Captain Tim Bamber, Mr Simon Evans and Mr Peter Jackson wants to read it. At the present time we do not know advice to benefit other members who may find what is being produced in fume events. It could be themselves in the position in future. They should any one of 97 diVerent chemicals. Hopefully we will keep copies of all relevant paperwork and tests and have data shortly. I specifically brought up this send copies of all relevant paperwork and tests to the question with the COT secretariat. I asked them IPA so we can maintain a central file should they “What would you recommend us to recommend to want to use the information later. Finally, as you are the pilots? Would you recommend blood tests at the no doubt aware, this is currently a highly contentious present time?”. The answer was no, because we do issue but be assured the IPA is actively participating not know what to test for. By the time we know what in getting a result and their help is essential. to test for it might well be helpful if they have blood tests within 12 to 24 hours at the latest. It has to be by Q214 Earl of Selborne: Are you aware of any airlines a recognised institute, et cetera. We would probably discouraging pilots from reporting fume events? be looking to modify this advice, when data starts Mr Jackson: Yes. coming through from the trials that the DfT are Captain Bamber: Reluctantly I would have to agree doing at the moment, to recommend a blood test to with that; yes, there are airlines who have issued see from their blood whether people have actually notices to pilots. The particular airline I am thinking suVered anything. There is genuine concern out of I am not going to name because they have been there. There are people who are sick and people are helping with our inquiries, but they did at one stage saying they are sick because of fume events. Whether issue an ASR flight crew notice saying that in certain that is true or not we have not yet proved, but circumstances fume events were normal and they certainly there are pilots who are sick and I am one should not be written in the tech log. of them. Mr Jackson: May I read you what we send our pilots? Q215 Earl of Selborne: Would Mr Jackson like to Because it is happening so frequently now we have add anything to his monosyllabic reply? put something together. I will put it in with our Mr Jackson: Yes. I said yes in such a way as to draw written submission. They should make sure they have your attention in fact to how serious the event is. The raised a technical log entry; that is to record the directive to which Captain Bamber refers has not defect. They should raise a mandatory occurrence or been rescinded to date, as far as our members tell us. a special air safety report and put it in to the company The company concerned is still actively seeking to because the CAA needs to know about it. They minimise the recording of such events. There is should send a copy of the MOR or ASR to our oYce another airline which is implementing other systems so we can track it through the system; from past of reporting which would not come forward on the history, a lot get lost. Should they manifest any of the Civil Aviation Authority’s database such as “Send an symptoms listed below—and we list the symptoms email to the chief engineer” and “Do it all through the which seem, from what we can draw using various back door”. websites and speaking to passengers, to be symptoms to look out for—or their company requires them to attend a local medical establishment after a fume Q216 Lord Colwyn: In the seminar which we had, event, whether in the UK or abroad, for blood tests and maybe it is just I who does not understand it, we they should ensure that they get a sample for heard that some aircraft have separate air supplies to themselves to bring back and ask how it should be cockpit and to cabin. Is that correct? stored. In consultation with their GP, or their area Captain Bamber: Yes. medical examiner, they may care to consider the following contacts: Biolab for the blood tests, Dr Q217 Lord Colwyn: I think there was disagreement Sarah MacKenzie Ross, from whom you heard a in the seminar and I did not really understand short while ago, because of her research; Drs Jamal whether it is diVerent aircraft. and Julu at the peripheral nerve and autonomic unit Captain Bamber: DiVerent aircraft’s engine systems at Imperial College Department of Neurology. We and air conditioning systems are diVerent, but some are also now seeking to find out specific lung function aeroplanes have a diVerent supply to the cockpit tests which seem in certain cases to be required, but from the rest of the cabin; the 757 is an example. we need to get a specialist to find out about that. Some do not. Their GP or AME should be able to arrange for these tests. Whichever doctor they use they should be sure Q218 Lord Colwyn: So the common fume events you to inform the other that they are doing it to keep talk about in 757s do not aVect the cabin. advice flowing backwards and forwards. If further Captain Bamber: The cockpit air for the 757 comes advice is required, they should contact the IPA’s from the left pack and cabin air comes from both oYce. They should keep the IPA informed on how packs. The cockpit air subsequently goes into the things are going and pass back any information or cabin. So the cabin will get the fumes which the 3844421010 Page Type [O] 30-11-07 13:08:07 Pag Table: LOENEW PPSysB Unit: PAG2

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10 July 2007 Captain Tim Bamber, Mr Simon Evans and Mr Peter Jackson cockpit gets. Seventy per cent of the air is re- pilot. Then every six months there is a cull of the circulated so it goes through a filtration system and unhealthy. By the time you get to 60 as a pilot you goes back into it. The re-circulated air will contain air would hope to live a lot longer than most other coming from the cockpit and if there are fumes in the people because you are a selected group of healthy cockpit, they will get into the cabin. people. There is a bit of controversy, but not as much controversy as people believe. The diVerence is that Q219 Lord Colwyn: And the pressure would be such some say yes, pilots are being made ill, let us see that it moves from the cockpit— whether this is the cause. Others say pilots are being Captain Bamber: No. I heard that as well, that there made ill, this must be the cause. That is the real was a diVerential in pressure between the cockpit and diVerence. the cabin but there is not. There is a slight air flow Mr Jackson: To answer your question, the cabin crew from cockpit to cabin, but there is no pressurised do not receive any payment. There is no facility for bulkhead door. that. Pilots, on the other hand, in the majority of companies in this country, are provided with loss of Q220 Lord Colwyn: It cannot be sealed in any way. licence insurance which can pay anything from Captain Bamber: No. £100,000 as a one-oV payment up to £250,000 if they lose their licence. As we are finding out, those who do Q221 Chairman: You would not be able to open lose their licence cannot claim this loss of licence the door. insurance because they cannot have a diagnosis on Captain Bamber: Yes. There is a flow. The cockpit air their medical condition. comes in and is used to cool the avionics panel. There is a stack of avionics in an aeroplane. So there is quite Q223 Earl of Selborne: A last question on this a high air flow and it tends to flow from the cockpit theme. We talked about monitoring and I do not to the cabin. Smells and things allegedly do not come want to go back to that; we have covered that very from the cabin to the cockpit as much. There is a flow fully. In your opinion, are there any other practicable in that direction but no pressurisation or anything preventative measures that could be put in place to like that. avoid fume events or to mitigate their eVects, if there are any? Q222 Earl of Selborne: Going on with the fume Captain Bamber: At the present state of knowledge, events a bit more, we have recognised that there is a the answer to that in my view is no. I emphasise that degree of controversy, or certainly lack of agreement it is at the present state of knowledge and I would at the moment about cause and eVect of fume events, hope that within two or three months the answer to to what extent they are implicated in long-term health that will be yes. The makers of filters said that they eVects or acute health eVects. That is also true of the can make a filter to filter out anything but they need Gulf War syndrome where the Ministry of Defence to know what to filter out. Until what is there is found pay soldiers who claim to suVer from symptoms a disability allowance because it cannot prove that the they cannot make a filter. Once we know what is symptoms are not due to exposure to certain causing the cabin air events, which is what we need neurotoxins. Are there any provisions for cabin crew the real time monitor for, it should be a fairly easy who retire early for reasons of ill health following process to fix it. The primary thing must be to see exposure to fume events? If not, do either of your what fume events are occurring and then a fix going organisations have any plans to advocate this? forward. A fix going forward is going to be a Captain Bamber: My organisation would prefer to see relatively easy thing to do to prevent pilots and crew initially proper care put in for sick pilots and then suVering these events in the future. Has-beens like perhaps look at representing the cabin staV. I agree me, who have possibly already suVered as a result, with what you said about the Gulf War; it is a good even on my scale, are third in the queue. The primary analogy. The diVerence with my position is that I am aim must be to find out what is happening and cure an agnostic; I want to be convinced. There are some it going forward. Then we can look at whether it has who are convinced and say the scientific proof is caused ill health, what ill health and what we can do there. I say let us set up the scientific experiment and about it. I am afraid that is the third rung really. prove whether or not there are cabin fume events, Mr Jackson: Should it be proved to be emanating which I am convinced there are, and whether or not from the engines, as commonsense would seem to they are leading to ill health. It is a diYcult thing to point us to think, it would be relatively simple to put investigate the ill health of pilots because there is no filtration in the pipe work which comes from the easy comparator group with which you can compare engines carrying the air. The only thing is that it them. We are a selected, healthy bunch of people would be very, very costly in the long term because all when we join, because anybody with serious illnesses the aeroplanes will have to be re-certified to carry it, or even relatively mild illnesses does not become a because of the eVect of putting a filter in the system. 3844421010 Page Type [E] 30-11-07 13:08:08 Pag Table: LOENEW PPSysB Unit: PAG2

52 air travel and health: evidence

10 July 2007 Captain Tim Bamber, Mr Simon Evans and Mr Peter Jackson

Q224 Chairman: I hate to bring it up again because of smell, so they would not actually detect anything. we have talked about it a lot, but it does occur to me One of the early toxicity eVects which happened in that this problem could be exaggerated. If there is a some of the diseases which allegedly are caused by fume event, do the pilots then have instructions to cabin air toxicity is that you lose your sense of smell report that and then a procedure go into place where as the first stage of the disease, so those who are most the filters are extracted from that cabin and tested susceptible to the eVects of cabin air toxicity will be following it? You do not need to carry monitors all the least able to record it. The other problem is a the time. You can have that or have a canister which regulatory one that airlines and parts of the Civil the pilot could open which could absorb a lot of the Aviation Authority do not particularly want pilots in atmosphere in the cabin and then close it and have it the event of fumes to be opening the end of a canister. subsequently monitored. Are there any procedures Their primary job is to fly the aeroplane. They do not like that in place? want something which takes them away from their Captain Bamber: There are several parts to your primary job. They are very loath to have anything question. I am going to tackle them from the bottom which is pilot activated. Our view on the Aviation up. As far as opening a canister is concerned, one of Health Working Group has always been that we need our testing devices which is being used in the current something which is automatic, that will monitor the phase of testing is more or less that; it looks a little bit whole time during the flight and eventually move on like a felt tip pen which is just uncorked at the to real time data capture. beginning of a flight and corked at the end of the Chairman: Unless the Committee have any other flight and it captures any SVOCs that are in there and questions, we have run quite late so we must bring it that goes oV to a gas spectrometer and is analysed. to a conclusion. Thank you very much for your That is a very straightforward and simple procedure. evidence. If anything occurs to you that you think we The problem with any pilot-activated device or pilot- should know, please let us know. Thank you very sensed device is that some people do not have a sense much.

Supplementary memorandum by the Independent Pilots Association The Association would like to raise the following points having reviewed the raft of submitted written and oral evidence:

Under-reporting of Cabin Air Contamination events, further research The Global Cabin Air Quality Executive (GCAQE) has recently conducted research of 242 past and present BAe 146 qualified pilots, 86% of whom had experienced contaminated air events. 57% reported various degrees of adverse eVects, 25% reported medium or long-term health eVects and 8.5% (number believed to be increasing) of the pilots appear to have medically retired or had their medical certificate withdrawn by the CAA. These figures are in complete contrast to the oYcial statistics that apparently show minimal contaminated events occur. As recently as 31 July 2007, DHL undertook a flight test on behalf of the Department for Transport (DfT) to demonstrate the ability of proposed test equipment to detect contaminated air events and quantitative air sampling. During the flight a contamination event occurred and the captain of the aircraft submitted an Air Safety Report, as required by the CAA, on the incident. To date this report has not found its way onto the CAA database. Where is it? A further demonstration of under-reporting. Further, the report of the flight test which is to include analysis by two independent laboratories of the samples taken is still awaited by the DfT. This Association feels this further demonstrates the apparent lack of concern by Government and airline operators to protect both crews and passengers health and is a basic failing in their duty of care.

Ability of aircraft passengers to gain meaningful help after suffering a perceived cabin air event The attitude of the respondents at the 17 July hearing of oral evidence when a letter from a concerned passenger was referred to was inexcusable and demonstrated the lack of gravity with which they viewed the case. The letter and writer were identifiable and from what was said it was self-evident that the writer was not able to express themselves very cogently. The respondents failed to grasp the main point highlighted by the letter, ie, there is no system in place whereby a crew member, passenger or group of passengers who consider 3844421011 Page Type [O] 30-11-07 13:08:08 Pag Table: LOENEW PPSysB Unit: PAG2

air travel and health: evidence 53 they have suVered adverse health eVects whilst flying on a British registered aircraft, can get accurate advice, impartial assistance and a thorough investigation to resolve and rectify the situation. This state of aVairs should not be permitted to continue.

Further evidence The Association has recently received a copy of a spread sheet listing the results of a series of blood and fat tests carried out on a group of pilots. The tests would appear to show that all those tested showed evidence of organophosphate contamination, 18.7% of which were specifically TriCresylPhosphate, together with a mix of other contaminants. These contaminants also appear in the list of substances found in the contaminated air tests conducted by Honeywell Aerospace (TOX/2006/39 Annex 11). The details from the spreadsheet can be found in Dr Sarah Mackenzie-Ross’s report to the COT, believed to be TOX/06/21 Annex 7 or 12.

Committee on Toxicity Report A great deal of time and eVort has no-doubt gone into compiling the report. Unfortunately it appears to pay scant regard and makes no recommendation to address the synergistic eVects of the many chemicals released into the cabin air system when a contamination event occurs. Similarly, clinical blood and fat test results as mention earlier have been disregarded. The Committee will not disclose why, even to the researcher who compiled the data. Also the report does not address the damage that is known to occur to both the human DNA and genes. There are papers published by several eminent Professors of Toxicology on the subject of which the COT is aware. The Committee states, “it would be prudent to take appropriate action to prevent oil or hydraulic fluid smoke/ fume contamination incidents” (para 28 of the report). Why it did not recommend the investigation of filtering and subsequent fitting of filters in the aircraft cabin air supplies is beyond this Association’s understanding. During the course of their investigation the COT have made reference to the fact that on many occasions, after an air contamination event MOR/ASR has been raised, the subsequent technical investigation found no engineering faults. It is due to the fact there was no aviation expertise within the committee membership upon which members could draw, that is was not appreciated that the modern jet engine has a maximum oil consumption rate (normally between one and two pints per hour) and any consumption below this level would not be considered a defect. It is therefore possible for an engine to be discharging oil through a faulty compressor bearing seal and hence into the air-condition system at or near to the engine’s maximum oil consumption rate without it being recognised or accepted as a fault.

A suggestion Whilst not wishing to rake over old ground the Association wishes to reiterate that it concurs with the submission by the GCAQE of the list of inaccuracies, misinformation and at times untrue information given by civil servants from various departments to the members of both Houses of Parliament. It not being helpful or practical to pursue the failures further the Association would ask the Committee to consider recommending that a line be drawn under these past failures and that all those engaged in resolving the problem of cabin air contamination go forward together in a spirit of openness, honesty and co-operation. From the reaction to the report that the Association is receiving from its members it has done nothing to ally their concerns that the “system” is only there to protect the interests of manufacturers and operators and the fact that crew members and passengers are at times being adversely eVected is of little consequence. This feeling is further compounded by the fact that 8 of the annexes to the COT reports were kept secret—for members only. How can such reports be peer reviewed and commented upon and confidence in the “system” re-established while such secrecy exists? 13 November 2007 3844421012 Page Type [SE] 30-11-07 13:08:21 Pag Table: LOENEW PPSysB Unit: PAG3

54 air travel and health: evidence

TUESDAY 17 JULY 2007

Present Broers, L (Chairman) Paul, L Colwyn, L Platt of Writtle, B Haskel, L Selborne, E Patel, L Wilcox, B

Joint Memorandum by the Department for Transport (DfT), the Department of Health (DH) and the Civil Aviation Authority (CAA) The Department for Transport (DfT), the Department of Health (DH) and the Civil Aviation Authority (CAA) note that the House of Lords Science and Technology Committee intends to inquire into aviation health and in particular to look at developments since 2000 when it published its last report on Air Travel and Health. Considerable advances have been made since then and the parties to this Memorandum welcome the opportunity to set out what has been achieved. The Memorandum follows the order of the questions on which the Committee has invited evidence.

What progress has been made in research into the priority areas identified by the Committee in 2000? Do gaps remain in the evidence base, and, if so, are they being filled? Greater numbers of people than ever before, and of variable general health, are flying. The understanding of health issues in relation to this growing population is therefore developing. We cannot in such circumstances list definitively gaps in evidence; as knowledge of aviation health issues grows, so research will be undertaken as necessary. However, we set out below important areas where research has been undertaken in recent years and where the Committee has expressed interest.

Deep Vein Thrombosis (DVT) The UK and the European Commission funded a World Health Organisation (WHO) research programme costingƒ2.8 million (to which the UK contributedƒ1.8 million from DfT and DH funds) to look at the incidence and mechanisms of DVT. Known as the WRIGHT project, the results of this two-year study showed that long-distance travel leads to a small but increased risk of DVT. The risk, which applies to all forms of travel, appears to be predominantly the result of prolonged immobility. A summary of results was published on the DfT website in December 2005, to promote understanding of the nature of the risk and higher risk groups. DH updated its web advice to reflect the findings. The WRIGHT phase 1 report is due to be published by the WHO on 28 June 2007. The WRIGHT team are seeking funding for a second phase of the study, to look at interventions. The UK would be sympathetic to contributing but the scale of study needed is likely to need international funding. DH separately commissioned research into the use of aspirin as prevention against DVT. The “Synovate” report was published on the DfT website in April 2006. This study examined the aspirin-taking behaviour of UK residents who were undertaking long-haul air travel. It found that 20% had taken, or planned to take aspirin before, during or after their flight. The DH website contains useful information on DVT and travel. Links to this information are also provided on the CAA’s Aviation Health Unit website.

Seating In response to the Committee’s recommendation a CAA funded research study into the relationship between aircraft seat dimensions and passenger size was published in 2001 and submitted to the Joint Aviation Authorities (JAA). Although the seat-spacing issue is not currently on the European Aviation Safety Agency (EASA) rulemaking programme, it will need to be addressed by EASA once it assumes responsibilities for regulation of operations, expected in early 2008. The CAA is the only regulatory authority to have made regulations on seating, which relate to spacing on safety grounds. The UK minimum seat space criteria require that the minimum distance between the back support cushion of a seat and the back of the seat in front is 26 inches in the upright position. Otherwise seat 3844421012 Page Type [O] 30-11-07 13:08:21 Pag Table: LOENEW PPSysB Unit: PAG3

air travel and health: evidence 55 pitch is a matter for individual airlines. Generally, first class and business class cabin configurations provide passengers with a greater amount of seat space than economy class cabins. Most airlines give information on their websites.

Ideal Cabin Environment (ICE) The UK is actively participating in the EU-led Ideal Cabin Environment (ICE) project. The Head of the Aviation Health Unit in the CAA is the medical chair of the project. The ICE project is concerned with both health and wellbeing in flight; it is the first study to address both these issues and will assist in the exploration of the relationship between them. The ICE project is therefore looking into the multiple eVects of long-haul travel with diVering cabin environment parameters (eg altitude, humidity, noise) on people of diVerent ages and also at “risk” groups with heart and lung disease.

Cabin air The principal gap in research evidence, and one which Government is now trying to fill, relates to potential contaminants in cabin air. Two important pieces of work are under way: (i) In 2006 the Aviation Health Working Group (AHWG) commissioned the independent Committee on Toxicity (COT) to look into the evidence submitted by the British Air Lines Pilots’ Association (BALPA) in relation to cabin air “fume events”. This work has been progressing for a year. The COT secretariat has agreed that the following information can be cited, although it is to be noted that the COT have not published a statement detailing conclusions at the time of writing. As well as from BALPA, the COT has received information from oil companies, airlines, engine manufacturers, independent scientific experts and pressure groups. The COT work, though not finished, is already increasing our knowledge of the reporting of fume events. For example, the COT has analysed the databases of BALPA, CAA and some airlines. In the BALPA database (up to April 2006), approximately 25% and 35% of reports on the database referred to the BAe 146 and the Boeing 757 respectively. A diVerence in the pattern of fume events was seen with regard to phase of flight. Thus, the majority of such events for the Boeing 757 appeared to be associated with take oV and climb whereas there was no discernable pattern with regard to the BAe 146/Avro RJ. The information submitted by BA to the COT showed that from 2002–05, a total of 197 reports were submitted on the B757 fleet related to alleged fume events. Two pilots made 38% of reports. Approximately 153 pilots did not submit a fume related safety report and the remainder (30) made one or two reports over the four year period. From the information submitted by Flybe to the COT about the BAe146/Avro RJ, it was noted that approximately 78% of crew reported one fume event, 12% reported two events, 5% reported three events, and 5% reported four or more events over the reporting period 2004–06. The COT is now preparing a first draft working paper which is not a finalised statement but outlines draft conclusions for further discussion. We expect this to be posted on the COT non food website towards the end of June. The Government has said it will be guided by the finalised COT statement in relation to further research but also asked for advice before the end of the review on in-flight air sampling, so that development of a project could progress as soon as possible (see below). (ii) Since 2000 both the CAA and BRE (Building Research Establishment) have undertaken research into this topic. The next stage is development of an exposure monitoring strategy. DfT is advanced in preparations for conducting research into cabin air fume events using a variety of test equipment. There are three basic questions to answer: (1) Is there any substance(s) in cabin air which is potentially harmful at the concentration measured? (2) Could this substance(s) cause acute symptoms?; and (3) Can continued exposure to such a substance(s) lead to long term ill health? From its analysis the COT has advised that 1,000 flight sectors need to be sampled to maximise the likelihood of capturing an oil-related fume event (as opposed to incidents of burnt food, toilet smells, etc). This estimate depends on the particular aircraft (engine/airframe combination) to be investigated. This approach should help to answer to the first of the three questions. Airline co-operation is vital. A similar proposed study in the USA has not yet found airline partners; DfT is very grateful for co- operation from airlines operating in the UK. As a preliminary to this research, functionality tests of the proposed sampling equipment are currently under way to examine how it performs in an aircraft environment and determine eVective positioning within the aircraft. 3844421012 Page Type [E] 30-11-07 13:08:21 Pag Table: LOENEW PPSysB Unit: PAG3

56 air travel and health: evidence

Long term effects from exposure to the aircraft cabin environment The CAA has undertaken a study in conjunction with epidemiologists at the London School of Hygiene and Tropical Medicine comparing cancers and causes of death in flight crew and Air TraYc Control OYcers (ATCOs) with the UK general population. Preliminary results have confirmed that flight crew have an increased risk of melanoma that previous studies have suggested, but have a significantly reduced risk of other cancers. Overall mortality and cancer incidence is lower than the general population in both these occupational groups and is similar for flight crew and ATCOs. The study has found no clear relationship between the mortality and cancer experience of flight crew with the cumulative number of flying hours.

Have any new health concerns emerged since 2000, and what is being done to address them? For example: are steps being taken to address concerns over the role of air travel in the spread of diseases such as SARS or pandemic influenza? Subjects raised at recent AHWG (see paragraph 17) meetings have included: defibrillators, disinsection, toilet facilities, flying when pregnant and cockpit light levels. It is important to distinguish between health issues which might be caused by flying, and health problems which may be transmitted into a country by air travel. These latter issues include SARS and pandemic flu which can be brought into a country by any transport mode. The International Health Regulations (IHR) 2005, which were adopted by the WHO in May 2005 and which come into force globally on 15 June 2007, aim “to prevent, protect against, control and provide a public health response to, the international spread of disease in ways that are commensurate with and restricted to public health risks and which avoid unnecessary interference with international traYc and trade”. They provide for the WHO to make recommendations on how to respond to the risk of international spread of disease. DH is currently consulting on changes that might be made to the Public Health (Control of Disease) Act 1984 in the light, amongst other things, of the IHR 2005. Meanwhile, local authorities remain responsible for port health: the Health Protection Agency (rather than individual Primary Care Trusts) now has the operational lead in England for providing local authorities with the health input they need to discharge that function. The current process if there is a suspected case of infectious disease (including SARS or pandemic flu) on board is for the pilot of an inward bound aircraft to notify the Port Health Unit of the receiving airport and implement recently revised IATA guidance with respect to action taken by cabin crew to prevent possible spread. If required, the sick passenger would be assessed by Port Health staV onboard the aircraft upon landing or taken to the Port Health Unit or directly to hospital. Much work is being done to ensure preparedness for a possible flu pandemic and for other contagious diseases such as SARS. DfT has worked closely with airlines and airports and other modal operators to ensure they have preparedness plans in place. This includes taking part in planning exercises involving other Whitehall departments, local authorities, transport providers and operators. In addition the International Civil Aviation Organisation (ICAO) has introduced a standard for Contracting States to establish a national aviation plan in preparation for an outbreak of a communicable disease. DH and Cabinet OYce have already published a national framework for responding to an influenza pandemic and DfT is about to start considering, in conjunction with CAA’s Aviation Health Unit, a national aviation plan in the light of that framework.

How effective has the inter-departmental Aviation Health Working Group been in taking forward the Committee’s recommendations? The establishment of the Aviation Health Working Group (AHWG) was part of the Government’s response to the Committee’s report of 2000. It first met on 26 March 2001. The function of the AHWG is to bring together relevant government agencies, to enable them to engage with stakeholders and to advise Ministers. It is chaired by DfT and includes DH, the Health and Safety Executive (HSE), airlines, Trades Unions, the CAA and the Air Transport Users Council (AUC). Notes of its meetings are published on the DfT website. There is also a research sub-group which meets under the chair of the DH to consider research proposals and needs. In full, the remit of the AHWG is: “The Aviation Health Working Group will meet on a regular basis and will work in partnership with other interested parties to give eVect to the Government response to the House of Lords Inquiry into Air Travel and Health. Particular responsibilities identified in the response are to: — provide a forum for interested Government departments and agencies to consider issues relevant to aviation health; 3844421012 Page Type [O] 30-11-07 13:08:21 Pag Table: LOENEW PPSysB Unit: PAG3

air travel and health: evidence 57

— provide an interface with the air transport industry, health experts and other interested parties on aviation health issues of mutual interest; — evaluate the need for research into issues related to air travel and health, and consider the role of Government in supporting such research; — ensure Ministers are kept informed and receive comprehensive advice on aviation health matters; — monitor developments that impinge on the health of those travelling by air.” The AHWG may invite to its meetings speakers with expertise on aviation health issues. These have included Crawley Borough Council (covering Gatwick) to talk about disinsection and Pall Aerospace to talk about air filtration technology. The establishment of the AHWG has brought industry and government agencies closer together, not just through meetings but by embedding day-to-day contact as part of the working culture. The AHWG has adopted an approach based on openness and information gathering to underpin policy. It has recently reviewed its operations and agreed to invite representatives of aviation construction and manufacturing to attend in future.

How are the arrangements for governance and regulation of the industry working?

In addition to the establishment of the AHWG, there have been two substantive developments since 2000. First, the law governing aviation health has been amended. The Civil Aviation Act 2006 charged the Secretary of State with “the general duty of organising, carrying1 out and encouraging measures for safeguarding the health of persons on board aircraft.” The functions of the CAA as set out in section 3(c) of the Civil Aviation Act 1982 were also amended to include the health of persons on board aircraft. This change was welcomed in Parliament. For example, John Smith MP said: “. . . it is radical and courageous. By creating the aviation health unit, the Government became the first in the world to provide such an institution. Under the auspices of the Bill, the Government will be the first to create a Minister for aviation health and to finance the aviation health unit, which is part of the Civil Aviation Authority at Gatwick, with a levy on the industry. The Government have a commendable record that sets an example to the rest of the world . . . They made the largest single financial contribution to the WHO’s study of the health risks of travelling, especially the risk of developing deep vein thrombosis . . . I congratulate and commend the Government on the lead that they have shown in the past few years by making Britain the only country to make available . . . specific health advice for passengers about to engage on long-haul travel.” Second, and in response to the Committee’s report of 2000, an Aviation Health Unit (AHU) has been established in the CAA to improve understanding and knowledge of these issues. This unit, which acts as a focal point for aviation health issues in the UK, was set up on 1 December 2003. It reports to the Chief Medical OYcer at the CAA. The Head of the AHU is a member of the AHWG and takes direction from stakeholder input via the AHWG Chair. Dr Annette Ruge, the first Head, has now moved to EASA and is still in contact. Dr Raymond Johnston, who currently heads the AHU, was selected by open competition last year.

How successful have the Government been in raising international awareness of passenger and crew health, and in improving international collaboration?

The UK has been an active participant in international co-operation, presenting at key international conferences eg the Scientific Meeting of the Aerospace Medical Association (AsMA), and the Congress of the International Academy of Aviation and Space Medicine (ICAASM). The UK is represented on the Medical Provisions Study Group of ICAO, which is tasked with reviewing and updating ICAO’s Medical Standards and Recommended Practices. The UK has advocated a move towards increasing the educative, and therefore preventative, aspects of the periodic medical assessments undertaken by flight crew and the incorporation of this within international regulation. The CAA is actively involved in the discussion in international fora of flight crew health issues which may impact on flight safety including the JAA, EASA, the International Academy of Aviation and Space Medicine, AsMA and ICAO.

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58 air travel and health: evidence

DfT has sought to foster international collaboration in the field of cabin air research into fume events. In this respect, the CAA and the Federal Aviation Administration (FAA) in the USA signed a Memorandum of Co- operation (MOC) with respect to joint research on “Cabin Air Quality” on 6 June 2007. DfT wrote to other members of the European Civil Aviation Conference (ECAC) in June 2006 to see if they had any experience of or research on fume events (some countries replied but not substantively).

What progress has the airline industry itself made since 2000? For example:

— To what extent has the aircraft cabin environment improved? — Are aircraft better equipped, and aircrew better trained, to respond to in-flight medical emergencies?

To what extent has the information supplied to travellers been improved and integrated since 2000? These are questions best answered by the aviation industry. With respect to information supplied to travellers we recognise that electronic communication via the internet is now the norm. Consequently the AHU is developing its website with FAQs addressing issues such as DVT, disinsection, carriage of medication and provision of therapeutic oxygen. 18 June 2007

Examination of Witnesses Witnesses:DawnPrimarolo, a Member of the House of Commons, Minister of State for Public Health, Department for Health,JimFitzpatrick, a Member of the House of Commons, Parliamentary Under- Secretary of State for Transport,MrsSandraWebber, Civil Aviation Division, Aviation Health Working Group, Department for Transport, andDrRayJohnston, Aviation Health Unit, CAA, examined.

Q225 Chairman: Welcome Ministers, Dr Johnston part of your deliberations in due course, which could and Mrs Webber. Thank you very much for coming prove helpful after today. to talk to us this morning. This is the Select Committee of Science and Technology’s inquiry into Q226 Chairman: Thank you very much. Shall we get air travel and health. I am the Chairman of the into the questions then? The first question really Committee. Welcome to members of the public. restates what you were talking about, but let me ask it There is an information note outside, if you have not formally. What progress has been made in improving already collected it. It is there for your purposes. flying conditions for passengers and crew since 2000? Perhaps we could start by the Members giving Jim Fitzpatrick: Structurally we have made evidence introducing themselves, please, and then, if important changes. We have amended the law. The you wish, making an opening statement. Civil Aviation Act 2006 charges the Secretary of Jim Fitzpatrick: Thank you, Lord Broers. May I State with “the general duty of organising, carrying make the introductions on behalf of my colleagues out and encouraging measures for safeguarding the and also add a couple of very brief comments? To my health of persons on board the aircraft”. The right, obviously, my ministerial colleague, Dawn functions of the CAA were also amended to include Primarolo, Minister of State for Public Health, on the health of persons on board the aircraft. This my left, Sandra Webber, head of Civil Aviation change is a world first, as far as we know, and was Division in the Department for Transport and Chair obviously welcomed in Parliament. We have also of the Aviation Health Working Group, and to Ms brought in the Civil Aviation Working Time Primarolo’s right, Dr Ray Johnston, Head of the Regulations 2004, which gave eVect to the European Aviation Health Unit at the Civil Aviation Union Council Directive 2000/79 on the working Authority. Sir, your report in 2000 was announced, time of mobile workers in civil aviation. To raising the profile of aviation health. Of course, complement those regulations we set up the Aviation shortly after came 9/11 and passenger safety has been Occupational Health and Safety Working Group to a priority for both ministers and the aviation look at certain aspects of crew health and safety in the industry. Nonetheless, I can say confidently that the cabin environment. The group is chaired by the CAA Government, the Civil Aviation Authority and the with membership drawn from airline unions. The airlines have responded actively to your group has been instrumental in producing guidance recommendations, and to demonstrate this we can on good health and safety practice in the aircraft present to the Committee an update on your cabin and its work has been widely welcomed. In Lordships’ recommendations from 2000 and the direct response to your recommendations in 2000, we current position which, obviously, you can study as have set up the Aviation Health Working Group, 3844421013 Page Type [O] 30-11-07 13:08:21 Pag Table: LOENEW PPSysB Unit: PAG3

air travel and health: evidence 59

17 July 2007 Mrs Dawn Primarolo, Mr Jim Fitzpatrick, Mrs Sandra Webber, Dr Ray Johnston which has brought industry and government agencies Q230 Chairman: So there is fume events, there is the closer together, not just through meetings but by normal atmosphere and then there is DVT. embedding day-to-day contact as part of the working Mrs Webber: Those would be the top priorities, yes. culture. The AHWG has adopted an approach based on openness and information-gathering to underpin Q231 Chairman: Why is the Independent Pilots policy. We have established in December 2003 an Association not represented on the Aviation Health Aviation Health Unit in the CAA to act as a focal Working Group when they have some 1,500 point for aviation health issues in the UK. Also, I members? would like to mention very briefly three important Mrs Webber: The Aviation Health Working Group research initiatives which I know we will have a reviewed its membership and its mode of operation at chance to discuss in more detail later on in this its meeting in April this year, including a request session. We have funded major work on deep vein from the IPA. The group decided that it had operated thrombosis co-ordinated by the World Health well and made progress because it was relatively Organisation, we have begun innovative research small, and that it already had a substantial work to investigate concerns about potential representation of pilots from BALPA (obviously the contaminants in cabin air—again a world first—and major pilots union) and also from cabin crew through we are actively participating in the EU-led Ideal the Transport General Workers Union, and decided Cabin Environment (ICE) project. not to include a further trade union but felt that the one gap it identified in its membership was the Q227 Chairman: Thank you very much. There are construction and manufacture of aircraft and if it several examples you gave of what has happened. were, therefore, going to enlarge its membership it Were they the result of discussions in the Aviation would like to have somebody to fill that gap. Health Working Group? Jim Fitzpatrick: May I invite Mrs Webber to respond Q232 Lord Patel: My question is properly addressed to that question, sir. in the first instance to you, Dr Johnston, and it relates Mrs Webber: Following up the recommendations of to the written evidence that you supplied, which says this Committee last time, we took that as the agenda. that the Aviation Health Unit was set up within the The Aviation Health Working Group has co- CAA “to act as a focal point for aviation health issues ordinated taking forward the various examples of in the United Kingdom”. Are you able to tell us, since research, and we started from the recommendations the unit was set up, what in practical terms have been which the Committee made last time and we also the advantages for air passenger health? commissioned a first piece of research from the BRE Dr Johnston: The unit was set up in December 2003 to look at what other priorities there might be for and I have been in post since April 2006. I think it research just to make sure that we had got the provides accessible reference data on aviation health programme worked out, and then those priorities matters to a wide range of stakeholders, it monitors were identified as things to do with the cabin and encourages research and keeps abreast of environment, both the regular cabin environment international knowledge of aviation health, and that and the cabin environment in the case of fume events involves myself contributing research papers to and also DVT. major medical meetings in the aviation environment, such as the Aerospace Medical Association, the International Academy of Aviation and Space Q228 Chairman: They would be your top three Medicine, responding to a number of queries from priorities for the Committee? both the general public and from crew and other Mrs Webber: They have been the top three priorities, stakeholders. yes, in the first period that the Committee has been operating. Q233 Lord Patel: Can you give examples of what areas of health, let us say two or three diVerent areas Q229 Chairman: Could you repeat them again? of health, that you are concerned about with respect There is the environment in the cabin, there is DVT to air travel? and what was the other? Dr Johnston: Specifically I carried out some research, Mrs Webber: There were the two aspects of the cabin which I presented at the seminar, on defibrillators, environment, there was the normal cabin co-ordinating information from a number of UK environment—that is the normal situation that carriers on the outcome of defibrillation on board people experience every time they fly—and then there aircraft. It was a very emotive subject and there was a is the particular aspect of fume events, which suggestion that defibrillation should be mandated on obviously happen relatively rarely, maybe about half aircraft, and the evidence from our study would a per cent of occasions. suggest that the outcome is rather diVerent in the 3844421013 Page Type [E] 30-11-07 13:08:21 Pag Table: LOENEW PPSysB Unit: PAG3

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17 July 2007 Mrs Dawn Primarolo, Mr Jim Fitzpatrick, Mrs Sandra Webber, Dr Ray Johnston aviation environment than it is in public places such of the Aviation Health Unit has increased in the past as football stadia or, indeed, main railway stations, year and certainly, by the number of calls and emails and that is probably due to the fact that the I get, I think people are aware of it but I am actively underlying heart rhythm upset that we see in the working to improve the visibility of the Aviation aviation population is rather diVerent from what we Health Unit for the travelling public. see out in the general public and it is not responsive to the same degree to electrical reversal. Q239 Lord Patel: What eVect would the European Aviation Safety Agency, when it is set up in 2008, Q234 Lord Colwyn: I do not understand that. A have on the plans that you have just now or the defibrillator reverses ventricular fibrillation and it is Aviation Unit has? the same, surely, whether you are in a football Dr Johnston: I think that would depend on what their ground, in the Palace of Westminster or at 36,000 interest in aviation health is, and myself and my feet? colleague Sandra Webber are going to visit EASA to Dr Johnston: In fact, one would think that, but if you discuss a number of topics, including that particular look at the prevalence of ventricular fibrillation and area. ventricular tachycardia, which are the two remedial rhythms, if one does a study in the general Q240 Lord Patel: Do you get the feeling just now in population, it appears to be of the order 70% of all your discussions that they are likely to take the cases. In the aviation population the data from the matter as seriously as the Aviation Health Unit airlines I have to date, and I am still receiving further currently do? information, would suggest this is of the order of 30 Dr Johnston: The answer is I do not know until I to 40%. Many of the individuals in the aviation speak to them in more depth. I think we take it very environment have other morbidity and illness and do seriously. This unit is a world first, and I would hope not have a rhythm which is remedial to electrical EASA would take it seriously also. reversal. Q241 Chairman: You are happy with the UK Q235 Lord Colwyn: But that means some are. representation on EASA? Dr Johnston: Some are, indeed, yes. Dr Johnston: Yes, I think I am. I think that EASA has legal powers. I think the UK is very forceful and is Q236 Lord Patel: What other examples are there? very determined to make sure that the accident rate Dr Johnston: The other examples I would give are in the United Kingdom, which is second none, is not people who telephone with medical conditions eroded, and I think high standards will be preserved. looking for advice in relation to travel (for example cardiac or respiratory conditions), often from the Q242 Chairman: How many members does it have? individual themselves or the physician, who may be Is every member of the EU represented? an expert in cardiology or respiratory medicine but Dr Johnston: I do not have that information to hand,1 would like to understand the aviation environment a but I can provide it. little more closely to help them understand the Mrs Webber: I think EASA represents, in a collective interaction with the patient’s condition and travel, sense, all the Member States of the European Union and I speak to both the patient or passenger who is but has a management board which has fewer than 27 travelling and the specialist physician and direct them on it, otherwise it would be unwieldy, but we can to a number of sources of information, including our provide that information. At the moment EASA is a own website. relatively new agency and it is gradually acquiring functions which were individually carried out by the Q237 Lord Patel: So if the passenger felt that, national aviation authorities—the CAA in the UK following air travel, they had caught some illness, are and the EU equivalents—and they are gradually they able to approach this unit? being accrued to EASA as it builds up its Dr Johnston: Yes, I have been approached. Normally competence. It has not yet really begun to tackle the they approach the airline directly. I would note their health issues, as opposed to certification of aircraft, concerns and liaise with the airline to get further but that is something that it is looking to develop. detail. Q243 Lord Colwyn: We have had many letters on Q238 Lord Patel: Have you known lots of passenger this issue, as you can imagine. I do not want to spoil to do this? your day, Dr Johnston, but can I quote to you from

Dr Johnston: I think increasingly our website, which 1 we have recently revamped, has an increased number Management Board of EASA. Norway, Iceland, Liechtenstein of hits—1,200 in the last month—and the awareness and Switzerland participate without voting rights. All the member States of the EU are represented on the 3844421013 Page Type [O] 30-11-07 13:08:21 Pag Table: LOENEW PPSysB Unit: PAG3

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17 July 2007 Mrs Dawn Primarolo, Mr Jim Fitzpatrick, Mrs Sandra Webber, Dr Ray Johnston one letter we had. This is a lady who suVered ill- obviously there are some risks associated with taking health, she felt, from a fume event possibly: “The aspirin as well under certain conditions which, again, CAA was the biggest fiasco I encountered with the traveller may not be aware of. That has led to, I telephoning and being passed around so many think, across all, the way advice is given to travellers, departments, no-one knowing who should deal with quite clear advice on when they should consult their this. I sent several emails regarding passenger health GP, under what circumstances. If I could go on, what and received two emails back stating that passenger is necessary and what is being considered now is, if health was not within their remit and was a matter for you like, a Phase 2, which will need to be a much the airline, as was consumer issues.” larger project. Phase 1 is UK-led, UK-funded and I Dr Johnston: I know the case to which you are think an absolute first in terms of consideration. I am alluding, and, with respect, my Lord, when this sure Dr Johnston would be able to talk more on this. individual lady contacted the Aviation Health Unit I Phase 2 is to look at what is eVective use when a risk oVered to review any medical data that she cared to is identified, whether socks or aspirin under certain provide. That medical data was not forthcoming and conditions. To actually try and get that we need a I repeatedly requested her to provide that much, much larger study for that, which means it has information and it has not been forthcoming. I would to go beyond the UK, and obviously we will look at be happy if she wishes to telephone me again. Myself contributing to it, but those discussions are now and my secretary have been in contact with this taking place. My apologies; that is rather a long individual. answer.

Q244 Lord Colwyn: I picked it at random. Q246 Chairman: Can I follow up there, I am sorry to Dr Johnston: I am sure, my Lord. interrupt, Lady Platt. How much of the Phase 1 study was carried out in the UK? Q245 Baroness Platt of Writtle: What Government Mrs Webber: There was a consortium, some UK sponsored research into aviation health has been and academics and a particular academic in the is being carried out in the UK since 2000? Netherlands; so some of it was done on Dutch Dawn Primarolo: The first major piece, I think, which subjects and some it was done in the UK. you will be interested in is the WRIGHT Phase 1. That was looking at the specific proposition: is risk Q247 Baroness Platt of Writtle: We heard from associated with long-haul over four hours Professor Michael Bagshaw in evidence on 10 July qualitatively, diVerent from other forms of travel? and he told us that not enough research was being That work, which was partly funded by the conducted in the UK. Indeed, he himself was unable Department for Transport and the Department of to get funding for research. What can be done Health, indicated that risk in certain groups can about that? double for over four hours but that the increased risk Dawn Primarolo: Forgive me, I am not aware of this is with all travel. It is about sitting still in confined point having been made. I think that the work that spaces for a long time. As a result of that research, has been undertaken to date was looking specifically firstly the findings were put onto both the at the identified areas of concern in health, to make Department of Health website in advice on travel and sure that we were giving correct advice and the Department for Transport. The World Health understood the risk. So early on it was about Organisation has recently published a final overview assessing risk; now it is moving forward. I do not by the researchers, which we will need to look at very know whether Dr Johnston would want to add any carefully to make sure that all the items are covered more. Now is the time in looking at what is eVective and refer it to our expert group. There was another against the scale of risk. I am not fully aware of the much smaller study also commissioned on the use of particular that you are referring to, but if that is in the aspirin, the perception of passengers, and whether area of how to deal with the procedures, then that is there were significant benefits or diVerences. I should where we are moving now. stress, this was a small study. Passengers were asked Dr Johnston: I think that your question is more about did they know about the use of aspirin, and there was what contribution has the Government made in a high response that they were aware of aspirin, but relation to research, and Sandra might like to give the then why or when they should take it or if they should figures on that and then I would be happy to address take it was a very low awareness. In stressing that this the Phase 2 questions. is a small study, there is no indication from that study Mrs Webber: Yes, in terms of DVT in particular, our that actually aspirin is eVective in reducing risk contribution was 1.8 million euros, which is because, as you will see from the Department of something over a million pounds obviously. In Health advice on its website, it makes it clear about addition, we have spent money on the normal cabin higher risk groups and what they should do, because air environment—I do not have the figure to hand 3844421013 Page Type [E] 30-11-07 13:08:21 Pag Table: LOENEW PPSysB Unit: PAG3

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17 July 2007 Mrs Dawn Primarolo, Mr Jim Fitzpatrick, Mrs Sandra Webber, Dr Ray Johnston but we could get it—and the research that we are just toolkit that is able to be slightly more interactive than embarking on, which we will talk about later in the advice that we currently have, and, of course, the relation to the fume events, we imagine might cost in same advice appears on other websites. It is also on the order of a couple of hundred thousand pounds. the Foreign OYce and the Department of Health So, I think in general, in terms of the general call on websites. Government research projects, we have earmarked money for the priorities that were identified and, I suppose, if anybody came to us with another aviation Q251 Lord Paul: There are various people but, health research proposal, we would consider it on looking at it, who should be responsible for this its merits. advice and what should be the role of the Government? Dawn Primarolo: Clearly the Aviation Health Q248 Baroness Platt of Writtle: Does the Working Group has responsibilities in making sure Government have a strategic remit in this area? that the issues are properly addressed, and there is Mrs Webber: I think the Minister mentioned the new advice to us, and then the departments have to ensure duty that the Government took upon itself in the that they are giving the correct advice on their Civil Aviation Act 2006 to take measures to websites. Lord Paul, I do not know whether you have safeguard the health of passengers on board aircraft seen, for instance, the Department of Health website. and I think we would regard conducting research At the moment it flags up advice on what you should fully within that remit. do under certain circumstances; it does not give you direct health advice. I think the onus is on all of us, as Q249 Baroness Platt of Writtle: Section 23 of the I understand it, I take very seriously my Civil Aviation Act 1982 restricts the CAA on how responsibility, as the Minister for public health, to they can use information from pilots’ medical make sure that the Department of Health is up-to- examinations for research purposes. Does the date and co-ordinated and clearly cross-referenced to Government have any plans to amend the Act to any other advice, and it is about access points. I do facilitate the epidemiological studies? not know whether, Dr Johnston, you could explain Jim Fitzpatrick: We are aware that this is a the way that the advice is interrelated so the access restriction, and the matter has been raised before us. points can be numerous but still end up with the We have not made judgment on it yet. It is something correct advice. that we are prepared to consider in due course, Dr Johnston: If I may, Lord Paul. On the Aviation because we do recognise that there will be value in Health Unit’s website we have constructed frequently sharing medical records for research purposes. So, we asked questions on the basis of the inquiries we have have not made that decision so far, but it will be had over the past year or so, and there is a specific one coming up in due course. for deep venous thrombosis which, I think, summarises the situation, and we have inserted the Q250 Lord Paul: Phase 1 of the WRIGHT project links into the WRIGHT study. If I could talk found that the relative risk of developing VTE for basically, although Phase 2 will address the specific passengers with existing medical conditions was issue of this risk environment, in general terms what doubled. In view of this, what advice should be given came out loud and clear from the WRIGHT study to airline passengers to prevent VTE? was that immobility was an important risk factor. Dawn Primarolo: The advice is provided, firstly, in a Therefore I think it is essential to encourage mobility, summary of the initial findings which was published and many airlines have helpful advice in their in- on the Department for Transport website in flight magazine and, indeed, one airline has a video December 2005 and on the Department of Health showing you specifically what to do, because they website, and that is to reflect the findings of that take health and well-being very seriously. If one is in report. Now the World Health Organisation a specific risk group, extrapolating (and I accept it is overview study has been published, it would be extrapolation) from the current risk groups in a appropriate to look again, with our expert advisers, surgical environment in which there has been much on whether or not this continues to cover all of the interest in recent publications in the British Medical advice that should be given. Should there be further Journal, if we look at a hierarchy of risk, low risk changes necessary as a result of this most recent mobility alone, as one enters a higher risk—recent overview, these will then be discussed between the surgery, hormone replacement treatment or the Department for Transport, the CAA and the contraceptive pill—one might think about stockings, Aviation Health Working Group, amongst others. I properly fitted as they are in hospital, and the next should add that it is very early days, but the stage will be pharmacological agents such as Heparin Department of Health is also considering whether it or, indeed, Warfarin if the individual, on specific should develop, if you like, a travel-related risk medical assessment, is deemed fit to be treated in such 3844421013 Page Type [O] 30-11-07 13:08:21 Pag Table: LOENEW PPSysB Unit: PAG3

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17 July 2007 Mrs Dawn Primarolo, Mr Jim Fitzpatrick, Mrs Sandra Webber, Dr Ray Johnston a way. But I think the message is loud and clear, if it Dawn Primarolo: Lord Paul is referring to the fact is immobility, that which works on immobility in a that I was a Treasury Minister for ten years. I think surgical environment, in the interim, until Phase 2 is it is not true that we bury the money in the Treasury, done, would be reasonable advice, but it should be Lord Paul. If we did, I would know where it was. specific advice for the specific individual and the Lord Patel: Would you spill the beans? specific environment. Q256 Lord Paul: Can I come back to low-molecular- Q252 Lord Paul: All these airlines are giving you weight heparin. How would a passenger know that advice that there should be movement, etcetera, but they might be the kind of person who would benefit when the flight is really full where does the passenger from that? go and walk? The moment he gets up he is told, “Can Dr Johnston: I think anyone who travels (and travel, you sit down, please?” like any other pastime, is a risk, and it is not a zero Dr Johnston: Having spent time in that part of the risk environment), if they have a medical condition, I aircraft to which you allude, the fundamental think they should discuss it with their physician. I important piece of mobility is to improve the venous think the knowledge has increased over the past few return, the blood flow in the leg, and one can actually years to general practitioners and specialists about move the feet up and down even in the particular the risks of venous thrombosis, and I think that, if seats to which you allude, and, if one wants to spend you are in a high-risk group, speaking to your money, there are little devices which will assist to specialist. There was a very good review article in the actually do that, but simple measures such as that, British Medical Journal. which often people think are not important, are fundamental to improving venous flow. The simple things are often much more eVective than the highly Q257 Lord Paul: You and I might read that, but is expensive drugs, which will have side-eVects, and I every passenger likely to read that? think that needs to be stressed. Dr Johnston: No, they are not reading that, but the physicians do, and I would hope they would read it Q253 Lord Paul: What else can be done to reduce regularly and be updated. The BMA has published this risk for vulnerable people? guidelines on air travel and I think that many Dr Johnston: As I say, one looks at the individual and members of the medical profession are members of their particular risk and targets that risk. If one was the BMA, and there is information there too and I in a very high risk group, one might think of what is think they can, when appropriately questioned, give called low-molecular-weight subcutaneous heparin, information to their patients. a simple injection, with a low risk of bleeding, which could help prevent deep venous thrombosis. Q258 Lord Paul: So can we be sure that none of these categories of patients travel without the advice? Q254 Lord Paul: The report of Phase 1 calls for Dr Johnston: Obviously it is very diYcult. The further studies to identify eVective preventive responsibility is on the individual to seek that advice. measures, which will comprise Phase 2 of the An individual may not seek the advice because they WRIGHT project. What plans will the Government do not know where to seek it, although I think there have to fund Phase 2? are multiple sources now and that has vastly Dr Johnston: I would hand that to my colleague, improved, or they may not seek the advice because Sandra Webber. they feel that, if they sought the advice, travel might Jim Fitzpatrick: If I may, Lord Paul, the final results be impeded and therefore they go unannounced. It is of Phase 1 of the WRIGHT study was published by interesting to note that the vast majority of in-flight the World Health Organisation on 29 June 2007. The emergencies are for conditions unknown prior to WRIGHT team are seeking funding for Phase 2, travel. which will aim to evaluate diVerent preventative measures and look into the eVects of interventions. The proposed cost of a Phase 2 study is four million Q259 Lord Paul: I am being diYcult, deliberately euros. The UK would support the principle of further trying to get you to a point where I hope we might get. studies but cannot pay for it alone. Given the For instance, everybody knows that pregnant women international nature of the work, we do believe that beyond a certain stage should not travel. The public European or global collaboration is the way forward, knows about that and they know they ought to ask and that is the basis we are working on. their GP or something. Why do we not give advice that says, if you have a cardiac disease or if you have Q255 Lord Paul: Your new minister has all the hypertension, cardiac failure or whatever, you should experience of finding the money! seek advice? 3844421013 Page Type [E] 30-11-07 13:08:21 Pag Table: LOENEW PPSysB Unit: PAG3

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Dr Johnston: On the websites which were alluded to in funded research study into the relationship between the final submission there is information, and I think aircraft seat dimensions and passenger size was that physicians do oVer advice. I would take minor published in 2001. This was submitted to the joint issue with the pregnancy statement, because many aviation authorities. Although the seat spacing issue people know there is a problem travelling in is not currently on the European Aviation Safety pregnancy but do not know the cut-oVs and I think Agency rule-making programme, it will need to be information is provided by airlines to clarify that, addressed by EASA once it assumes responsibilities and, indeed, major airlines, one in particular, has a for regulation of operations, expected early next year, very helpful website with health information and, as we discussed earlier. The CAA is the only indeed, a select bit of the website for medical regulatory authority to have made regulations on practitioners which allows that transfer of seating which relate to spacing on safety grounds. information. The UK is, thus, the only country to specify a minimum. The UK minimum seat space criteria Q260 Lord Paul: Would you encourage all airlines require that the minimum distance between the back- to adopt the procedure of this particular airline that support cushion of a seat and the back of the seat in you are not naming? front, as you mentioned, is 26 inches in the upright Dr Johnston: Yes, I think clear communication and position, and most airlines give information on their information allays anxiety and to prepare for travel, websites, but I am not sure if Dr Johnston wants to if you have a medical condition, is very important add some more information to that. and I think wider information is disseminated by a Dr Johnston: I think that has been well summarised in number of airline websites. I mentioned one in relation to EASA. Looking at the current European particular but there are other airline websites which and, indeed, Asian airlines, I could find no airline are also helpful. I think the individual has a which operates a 26-inch pitch, and also in that responsibility, if they have an illness, to do a risk report, my Lord, it said the seat pitch should be assessment, in their own mind to say, “I have this increased to 28 inches, and every airline that I have condition. Let us seek advice whether it is going to researched has a seat pitch greater or equal to 28 preclude travel”, because the majority of medical inches, and that includes scheduled carriers, charter conditions can be carried on airlines. carriers and, indeed, low-cost carriers.

Q261 Chairman: A lot of people do not use the Q263 Lord Haskel: Who is responsible for laying Internet, surprisingly, but they do not. Is there down a minimum seat pitch? literature placed in the waiting rooms of surgeries? Dr Johnston: At the moment in the UK we have a Dr Johnston: Luckily, my Lord Chairman, I have not been to my general practitioner for some time, but, minimum seat pitch, but until EASA examine this yes, there are hard copies of pamphlets on safe travel, when European operations come in, in 2008, the data etcetera, that are available, although, as we have said to which you allude is with EASA at present. before, the majority of information is moving towards the Internet and I think a number of people Q264 Lord Haskel: So at the moment any airline can one would think would not use the Internet do use it put any seat pitch that they want? quite successfully at all ages of maturity. Dr Johnston: I think that if an airline produced a pitch that was less than 26 inches, that would be a problem Q262 Lord Haskel: I wonder if we could move on to in the current legislation and, since no airline is near the question of seating and the seats on aircraft. In 26 and the minimum I found was 28 inches, I do not 2001 a CAA funded study was published into the think that situation would arise. If one got down to relationship between aircraft seat dimensions and 26 inches, I think the public, who are becoming passenger size. It seems that the impact of this study increasingly selective in how they travel, would vote was that it was studiously ignored. For instance, the with their feet. study found that “the current requirement does not provide enough space for taller passengers to adopt the ‘brace’ position. Seat pitch would have to increase Q265 Lord Haskel: Current minimum seating to at least 35 inches to provide an optimum safe brace spacing leads to passengers being unable to change position”. Is it rather irresponsible to have a posture and seating position at will. Also, you do not minimum seat pitch requirement of 26 inches? have much room to move your legs to assist the Jim Fitzpatrick: I will ask Dr Johnston to comment venous flow that you were telling us about. Do you further in respect of your secondary point, your think the Government should do more to encourage Lordship, but I can say it was in response to your airlines to provide seating as a standard which meets Committee’s recommendation in 2000 that the CAA the health needs of the passengers? 3844421013 Page Type [O] 30-11-07 13:08:21 Pag Table: LOENEW PPSysB Unit: PAG3

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Dr Johnston: I am passionate about evidence-based there is a European contribution to the WRIGHT medicine or evidence-based changes and until there Phase 2. So I do think that we in the UK do have a are data which suggest the current seating pitch good opportunity to influence the way EASA causes a health problem, I do not feel this is an urgent develops its programme, because the UK is issue. In the previous reports we have talked about renowned amongst European countries as being one dropping the title “economy class syndrome”. It is of the more advanced in terms of the whole history of not an economy problem. One can get a deep venous the aviation industry and aviation regulation, and I thrombosis in a business class seat and, indeed, a am sure we will have as much influence as anybody. first-class seat, and one could almost argue that if one had more space one might adopt a policy of not Q269 Lord Haskel: So you would see passenger moving at all, plus a little alcohol to help the health as one of the top priorities when you go to relaxation. So, I do not think there are data there to see them? substantiate a health risk in the current seat pitch, Mrs Webber: They have asked us to come and talk to and I have sat in a 28 inch pitch on a ski flight and I them specifically about that. They are already dealing could still move my feet in the appropriate manner. with a lot of safety issues, because they have started their work already and they are gradually Q266 Lord Haskel: So on what basis did the accumulating responsibilities, but they know they Government decide to levy a higher rate of air have got to take on health and they have asked us to passenger duty on the premium economy seating? come and help them develop their programme. After all, the premium economy seating is not necessarily a luxury; it is the space which is in line Q270 Lord Colwyn: In the answer to question one, with the findings of the 2001 research? or it may have been the introduction, Mr Fitzpatrick Dr Johnston: I will pass that on to my colleague. That said that the UK is actively involved on the EU-led is not my area of competence. Ideal Cabin Environment Project. I wonder if you Mrs Webber: I have to say that air passenger duty is a could actually say what the goal of this research is Treasury decision, but I can say that I believe that and what impact do you think it will have on health and safety were not relevant to the decision, it government policy? was taken on economic and financial grounds, and, Jim Fitzpatrick: If I may invite Dr Johnston to indeed, as Dr Johnston was saying, had no health or respond to those questions. He is the medical chair of safety impact because there is no link, and I believe, the ICE project, so he is ideally suited to give you as some of the airlines mentioned when they gave what you need by way of an answer. evidence here, they were not happy about where the Dr Johnston: Thank you. The Ideal Cabin borderline fell in the Treasury decision and they are Environment is a pan-European project which still discussing with the Treasury whether they can addresses the European Strategic Agenda to a highly persuade them to make any change. customer-orientated air transport system and really arose from the concern about health, well-being and Q267 Lord Haskel: So is that one of the things that comfort of passengers. It is unique in its approach, you will take to the European Aviation Safety looking at health and well-being, and the concern has Agency when it assumes responsibility for also increased with the changing passenger regulations in 2008? demographics in that a larger proportion of more Mrs Webber: They will not have any responsibility for elderly passengers are travelling. The figures from tax collection. The air passenger duty is a tax, and Stansted show that from 2000 to 2006 the number of that will not come into it. passengers over the age 60 has increased from 11% to 17%; so a significant increase in the older passenger. Q268 Lord Haskel: So are you going to make any My particular role is to ensure the total integrity of other representations to them apart from this matter this project, to provide guidance to the project teams of seat spacing? and to ensure that the consortium takes account of Mrs Webber: EASA is developing its competences. It other pertinent research and to chair the stakeholder started out with aircraft registration and I think the workshops. What we want to look at, the key next phase it is moving on to is the pilot licensing objectives, are the impact of cabin pressure (ie area, and it is looking to take on health altitude) on aspects of well-being and health, the responsibilities in the future. They have asked us to interaction of the environmental comfort factors, go and visit them, which we will be doing in the their variation over time and their relative autumn, to talk about what we would see as the contribution and sensitivity to changes that we might priorities we would want them to pursue, and one of make. The population that we looked at was those would undoubtedly be, for example, to approximately 1,500, equally divided, 50% male and contribute to the WRIGHT Phase 2 or to ensure that female, in three particular age groups, 3844421013 Page Type [E] 30-11-07 13:08:21 Pag Table: LOENEW PPSysB Unit: PAG3

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18-34, 35-50 and 50 years plus. In addition, because Q273 Earl of Selborne: Dr Johnston has said that of the perception of cardiac and respiratory problems vulnerable passengers have a responsibility to take causing a risk in travel, we had a subset with cardiac advice before they travel, and I imagine that most and respiratory disease. A number of environmental would seek advice from a GP. Could you tell us what conditions were examined—temperature, relative has been done to enhance GPs knowledge of health humidity and a range of cabin altitude from ground implications of air travel and to what extent have the level to 4,000, 6,000 and 8,000 feet. Psychological medical royal colleges and other medical groups been well-being was also assessed by questionnaire and, in involved in disseminating such advice to GPs? addition, heart rate variability and monitoring of Dawn Primarolo: Clearly Dr Johnston has touched on skin electrical changes to address the stress issues. the research that is published and that doctors have This work was done on two ground-based facilities, access to and read, but there is more information firstly in the UK at the Building Research online to advise particularly GPs on this issue, and Establishment in Watford and the Fraunhofer test for members of the British Medical Association, the facility near Munich. Both these rigs consisted of a BMA produced a document and circulated it on the forward fuselage of an Airbus wide-bodied aircraft impact of flying on passenger health. So there is a which can be configured to a variety of seating great deal of information that is disseminated to GPs pitches to replicate either economy or business class, to make them aware (if they are aware that their and this study was done in an economy pitch. patients are travelling) of what advice should be However, the test rig in Germany is unique within given vis-a`-vis their conditions. Europe in that one can change the pressure within the rig to simulate altitude. The ultimate aim of this Q274 Earl of Selborne: To what extent have the project is to set a new European standard once the medical colleges been involved in disseminating this data are analysed. The study was completed and consulting particularly on some of the approximately eight weeks ago and the data are specialities? You might be able to give special advice currently being put into the database and the study on particular conditions. will report formally towards the autumn 2008. Dawn Primarolo: I believe that that advice is available, but I will double check and give you a note on that with specifics. The GP, particularly where Q271 Lord Colwyn: That sounds very their patient has a condition that would make them comprehensive. So, could you be confident and say high risk, should already, one assumes, be aware of that, in your opinion, this study will go some way or this and have flagged it up to their patient, whether will it completely put an end to the current concerns or not they know they are travelling, in case they are about cabin air quality, humidity and cabin pressure travelling, but I will certainly go back. Forgive me; I that is raised by passengers and crew? do not have that information before me on the Dr Johnston: I think it will produce some excellent particular role of the royal colleges. I do not know data. I mentioned earlier I was passionate about whether Dr Johnston might know that. evidence. I think we will have evidence on humidity Dr Johnston: Things have changed, as your Lordships figures, we will have evidence on altitude, ie cabin may be aware. The content and standard of training pressure, and we will have evidence on heath and in relation to physicians is really now the well-being; and getting all those parameters together responsibility of the Postgraduate Medical for the first time, I think, will be a major step forward. Education and Training Board (PMETB) and the The other concern you mentioned, cabin air, will be General Medical Council has the particular role of addressed in further research we will talk about ensuring that students and newly qualified doctors perhaps a little later in relation to measuring in a real are equipped with the knowledge, skills and attitudes aircraft, not an artificial situation, what exactly is in essential for professional practice. As regards the cabin air. Royal College of Physicians in London, myself and my colleague, the Chief Medical OYcer, Sally Evans, are talking on aviation issues to the college in October and the college sees this as an area of Q272 Lord Colwyn: So you are confident? interest. Dr Johnston: I am extremely confident. I think it is a world first, it is innovative and it is a privilege to work on this project because its pan-European, people are Q275 Earl of Selborne: The British Thoracic Society coming from a lot of diVerent directions, but they are has published excellent guidelines on managing all passionate about saying, “Let us get the evidence passengers with respiratory disease planning air and then work on the evidence and not anecdote, travel, and this is clearly an excellent example. Do because only with evidence can we move forward.” you think that the Aviation Health Unit should 3844421013 Page Type [O] 30-11-07 13:08:21 Pag Table: LOENEW PPSysB Unit: PAG3

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17 July 2007 Mrs Dawn Primarolo, Mr Jim Fitzpatrick, Mrs Sandra Webber, Dr Ray Johnston encourage other specialist organisations to prepare improved, to join together more information, similar guidelines? making sure that GPs and travellers are aware of Dr Johnston: My Lord, I think that would be potential risks and the right questions to ask and, interesting and I think it is again getting more therefore, the solutions to mitigating that risk. evidence. The particular meeting to which I allude in October is being organised by cardiologists, and I Q278 Lord Paul: Given the change in the think that would be an excellent window to raise this. demography of the flying public and the prediction I agree with you that the BTS guidelines are a that by 2030 older people will outnumber younger significant way forward. adults by a fifth, should the Government take the lead on recommendations on fitness to fly? Q276 Earl of Selborne: If you get these specialist Dawn Primarolo: I think that actually Dr Johnston groups such as producing reports on respiratory touched on some of that when he talked about the diseases together and then you get the cardiology, demographics, the travellers in terms of diVerent orthopaedic, psychiatry, why could you not get them airports, diVerent carriers and the changing age all, together, to produce eventually a comprehensive profile and, therefore, the need to have the evidence guide for GPs so you have got the whole lot there in associated with understanding the composition of the an accessible form? travelling public. Therefore, yes, given that we would Dr Johnston: One of my future aims in the Aviation follow the evidence, you could see it emerging that Health Unit, but it is no mean task, which does not there would be specific advice for a particular age mean to say I do not accept the challenge, is to try and group but, let us be clear, risk exists across all the age bring this disparate information into one area, ie the ranges. We are healthier, Lord Paul, even though we Aviation Health Unit, and somehow give serious may be older and, therefore, age may not be the consideration to it. I think it is an excellent determining factor, I think, certainly in my case suggestion. anyway. So, in short, yes, we have got to keep looking at the evidence, where it directs us and making sure Q277 Lord Paul: What is your assessment of that the appropriate advice is available to the information available to passengers and general traveller through all the diVerent websites and, of practitioners on fitness to fly? How does it diVer from course, to the medical profession on what would be what it was in 2000? appropriate mitigation of any risk. Dawn Primarolo: I would hope, through the progress of this morning, that you would agree with our Q279 Lord Paul: Should the National Institute of assessment that the quality and availability of Health and Clinical Excellence be involved in information is much improved, both through the recommending best practice with regard to travel Department for Transport, the Department of advice and fitness to fly? Health, the CAA, plus the excellent work of the Dawn Primarolo: I think not, Lord Paul. I think the Aviation Health Working Group, and, of course, Health Protection Agency is the appropriate body during this time (and I heard the point that was and has the remit to do that. The remit for NICE is made) not everybody would have access to the quite diVerent and, therefore, I do not think it would Internet, but, nonetheless, we have seen enormous be appropriate to ask NICE. If the Committee has growth and development as the main method of observations about how the Health Protection transmitting advice to travellers. I have touched on Agency might improve what it is doing, then of this before, the Department of Health website is course we would take those comments on board. clearly sign-posted and there are links to the necessary other sites now that the Department of Q280 Lord Colwyn: Do you think there is a case for Health has transferred the function of providing standardised guidelines for carrying ill or vulnerable travel health advice to the Health Protection Agency passengers across all airlines and, if you do, who do in 2003, but the Health Protection Agency is working you think should take ownership for the in partnership with the National Travel Health responsibility? Network Centre and, likewise, Health Protection in Jim Fitzpatrick: We have covered some of this Scotland and, of course, the Aviation Health Unit territory earlier on, your Lordship, in the provides links to websites for travellers as well, as proceedings, but it is our view that freedom of does the Foreign and Commonwealth OYce website. passage and personal mobility is obviously very So, there are a large number of places where that important and we do a great deal to encourage and information can now be got. The information would facilitate it. Of course, all travellers must exercise be, if you have these conditions, you should consult personal responsibility. I would like, if I may, to refer your GP and, as we have explored through the to two examples of the facilitative role that we session this far this morning, that needs to be undertake. First, on disabled passengers, new 3844421013 Page Type [E] 30-11-07 13:08:21 Pag Table: LOENEW PPSysB Unit: PAG3

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17 July 2007 Mrs Dawn Primarolo, Mr Jim Fitzpatrick, Mrs Sandra Webber, Dr Ray Johnston regulations concerning the rights of disabled is useful at the moment and, having reviewed all that passengers and persons of reduced mobility when information, the correlation between the information travelling by air are being introduced to bring aircraft is fairly close. One always says in research, in line with the Disability Discrimination Act 1995. “Triangulate the data for good evidence.” Bringing These come in next week, if I am correct. They will these competences together would certainly be a way give disabled people new rights for travelling by air in forward in that respect. Europe and will ensure that no person can be refused carriage on a commercial flight starting and finishing within the European community on the basis of their disability or reduced mobility. The regulation was an Q282 Lord Patel: If next November there was a important achievement of the UK’s Presidency of the report of an outbreak of pandemic ’flu in the United EU in 2005. Secondly, on pregnant passengers, the States, what action would that trigger in the aviation Gender Directive will make it an oVence to industry? discriminate against passengers on the grounds of Jim Fitzpatrick: Much work is being done to ensure pregnancy. We are consulting with the Royal College preparedness for a possible ’flu pandemic or for other of Obstetricians to make sure that we have a contagious diseases such as SARS. The Department workable position for passengers and airlines. Of for Transport has worked closely with airlines and course it would not be sensible for people who are airports and other modes of transport operators to clearly too ill to travel to do so. That is why, for ensure they have preparedness plans in place and example, the European Passenger Restricted contingency planning exercises have taken place also. Mobility Regulation includes provisions for the The international aspect of preparations is very refusal of carriage in specific circumstances on the important. In addition to our own preparedness, the grounds of legitimate health and safety concerns. International Civil Aviation Organisation, ICAO, in Those who have specific medical conditions should, conjunction with the World Health Organisation and as we discussed earlier, and do generally take advice the International Air Transport Association, has from their GPs or from specialists who can advise introduced a standard for contracted states to them on travelling. On balance, we do not think there establish a national aviation plan in preparation for is a need for standard guidelines. We want to enable an outbreak of communicable disease. There is a lot air travellers to make informed and responsible of work going on, as you know, within government decisions themselves on whether or not to travel, generally to prepare in respect of a ’flu pandemic although, notwithstanding that we believe the which is a health issue but obviously transport will current system operated by airlines works well, we have an important role in our response and this is a obviously have the comments from Dr Johnston matter which is under active consideration within the earlier on about particular guidelines which might be Department. more appropriate.

Q281 Lord Colwyn: I do not think I fly enough to Q283 Lord Patel: At this stage you do not know have personal experience on this but the guidelines on what action that would trigger in the aviation pregnancy or people who have recently undergone industry? surgery– and another problem that is often forgotten Jim Fitzpatrick: It would be very diYcult to is people who are going to have surgery—it is very anticipate fully all the potential actions which may be important that they know about the problems of required. There are guidelines in place in respect of flying. Should the government or the CAA look into certain aspects. There are recommendations from the this and try to standardise it? World Health Organisation in terms of countries’ Dr Johnston: It is an individual assessment. The preparedness but we are working up a more definitive earlier suggestion of bringing together the disparate statement of policy. Indeed, I think we have a specialties and breaking down the areas of meeting coming up next week which Mrs Webber competencies would be a way forward. There are might be able to give a little more information on. standard guidelines produced by the Aerospace Mrs Webber: If your question was what specifically is Medical Association, the BMA and other individuals in these preparedness plans, I do not think we are at and they are very similar. Another thought that I the stage of giving the detail at the moment because have is to try to bring these together in one focus in it is still an active project. Obviously that is the aviation health unit on the website. The point you something that airlines, shipping and other make about having appropriate advice in one place is international transport operators know they have a diYcult because if it is only in one place and the role in, providing information to the health individual does not know about that one place they authorities and protecting people who look ill when are almost disadvantaged. The spread of information they are on board. 3844421013 Page Type [O] 30-11-07 13:08:21 Pag Table: LOENEW PPSysB Unit: PAG3

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Q284 Lord Patel: One of the key facets of the overall with a high fever and without you are more likely to plan for pandemic ’flu was containment of the find infected people with a high fever, are you not? pandemic in the area where it first occurs. Therefore, Dr Johnston: I would concur with your friends and movement of people out of that area will be colleagues who have notified you about temperature. important. What you are saying is at this stage we have no plans for what the aviation industry would Q288 Chairman: I do not accept their argument for do because that is the industry that would be one moment. If you take 50 people who are running responsible for moving people around. a fever of 104, it is far more likely that more of those Mrs Webber: I do not think it is fair to say we have no are infectious than if you took 50 people who were plans. The plans are being developed and refined but not running a high fever. if something happened tomorrow the planning as it Dr Johnston: Absolutely. With the incubation period has got to— in pandemic ’flu, being diVerent from SARS, the temperature screening has a limited value. It may Q285 Lord Patel: November was my target date. have some value but health screening in terms of a Mrs Webber: There will be plans in place but in terms questionnaire before someone left an area—you of talking of containment there will be stages, alluded very astutely to containment. Screening can depending on the level of the threat. Clearly, be more than temperature measurement. It can be a cancelling all flights is the last resort, not the first simple questionnaire on one sheet of A4 asking about resort. There will be levels of activity depending on their wellbeing before they get on the aeroplane. All the risk assessment at that stage. these methods are not without failings because if someone is desperate to leave area “A” they may well say they feel well. If they are in the early stages before Q286 Lord Patel: You already have a plan that says they become ill with a high temperature, they will that one of the things in any pandemic, particularly leave anyway. I do take your point that temperature pandemic ’flu, would be to try and contain that into screening may have a role but I think it might not be the area where it first occurs to minimise its eVect or the most vital role in a pandemic ’flu epidemic. allow us even a few days to prepare for that pandemic. If there are no plans for people moving out Q289 Lord Colwyn: The filters on these aircraft are of that area and arriving here, then we cannot obviously eVective against molecules. Are they not contain that. eVective against viruses? Jim Fitzpatrick: If there was a suspected person on Dr Johnston: The HEPA filters we talk about are board, there is a clear process in place whereby that 99.97% eVective in removing bacterial viruses. The individual passenger and the fellow passengers would problem is, in infection, on the route of spread. One be monitored. There is a process for isolation to take can become obsessed by droplet spread but it is often them to the appropriate port health authority for droplets on the hand and touching so good hand dealing with them. If there is a ’flu pandemic that hygiene has been shown by many experts to be highly develops there will be conflict because there will be eVective. If one is travelling for example to Heathrow citizens in diVerent parts of the world who will be and cannot aVord the Heathrow Express and travels desperate to return to their home country. This will on the tube, one’s respiratory tract and hands are be a matter that will be judged dependent upon the close to total strangers and you do not know their circumstances that apply at the time. The history either. The whole journey, because you are government has well laid plans laid down and with a large number of people, can be a risk rather corporate exercises have been taking place for some than just the aircraft per se. The flow patterns on the time now to make sure that, wherever the pandemic aircraft would mean two rows in front, two rows occurs and breaks out, there will be an appropriate behind of any suspect case so the HEPA filters are a government response. We are refining the highly eVective method of removing bacteria and Department for Transport’s response in terms of viruses. dealing with our responsibility there too. Q290 Lord Colwyn: My medical colleague has just Q287 Chairman: I could not help but notice, flying reminded me that ’flu of course is a bacterium. into Hong Kong a few weeks ago, that they are still Dr Johnston: It is a virus, with respect. monitoring the temperature of everybody arriving in Hong Kong. That strikes me as not an unreasonable Q291 Lord Patel: My question was very specific. It thing, especially if there was a state of high alert. Do was not about transmission of infections on an we have equipment to do that? I know all doctors tell aircraft. It was about if there was a report of a ’flu me that people can be infectious before they have a pandemic in the United States in November. What temperature but if you take a population of people action would that trigger in the aviation industry—ie, 3844421013 Page Type [E] 30-11-07 13:08:21 Pag Table: LOENEW PPSysB Unit: PAG3

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17 July 2007 Mrs Dawn Primarolo, Mr Jim Fitzpatrick, Mrs Sandra Webber, Dr Ray Johnston are we going to stop flights to contain the disease The campaigners attribute their health symptoms to where it is or are we going to allow free movement of organophosphates in mist from heated engine oil or people and allow the disease to come here? hydraulic fluid which has leaked into the cabin Jim Fitzpatrick: We are not in a position to give a because of design or maintenance faults. Your definitive answer on that. It would very much depend Committee looked into this in 2000, particularly the on the circumstances. There are preparedness plans organophosphates and tri-ortho-cresyl-phosphate, in place for the industry. The Department is working known as TOCP, which I will refer to it as, and closely with the airlines to make sure that they have concluded that the very low levels of TOCP that their plans in place. It may very well be that that would be found even in the highly unlikely worst case would be a consequence but I could not say this of contamination from oil leaking into the air supply morning that that is what we would do. lead us to conclude that the concerns about Chairman: How big is the ’flu virus? significant risk to health of airline passengers and Lord Patel: Pretty small. crew are not substantiated. Nevertheless, your Chairman: I know the polio virus is only 15 Committee also recommended sampling of cabin air nanometres in diameter and that is likely to pass during both normal and abnormal operations. Since through a HEPA filter. 2000 there has been further research on cabin air quality during normal operations and the quality is Q292 Lord Patel: The answer that Dr Johnston gave found to be very good. Taking air samples during is that the majority of the viruses will be caught by a fume events did not turn out to be, if I can quote your HEPA filter, but not all of them. report last time, “a simple and inexpensive exercise”. Dr Johnston: The figure of 0.3 microns comes to mind. We have just begun a ground breaking research project, a world first, using experimental technology. Q293 Lord Patel: If it is H5N1. There are three reasons why it has taken so long to Dr Johnston: Yes. Who knows? It may change again reach this point. Typically, cabin air is exchanged before the pandemic occurs. every two to three minutes and cockpit air every minute, so you need sampling equipment which can pick up transient contaminants. Also, the equipment Q294 Lord Colwyn: It is still widely felt that if you go must not interfere with flight safety either on an aircraft and someone at the other end has a mechanically or by distracting the crew during a fume cold you are going to get a cold a couple of days later, event. Finally, fume events occur in perhaps half to is it not? Is that an old wives’ tale? one per cent of flights so we would need equipment on Dr Johnston: If I can address that particular point and many flights to maximise the chance of capturing the consider the passenger journey. If there is a person at fume event. Cost is a consideration in terms of the the front of the aircraft, who may be in first class, and devices, the space they occupy and the analysis. We you are sitting at the back of the aircraft and it was a have begun testing various sampling devices. These coaching departure, the respiratory tract of the first include solid phase micro-extraction devices, class passenger might have been in close proximity to SPMEs, photo-ionisation detectors, PIDs, and a that of an economy passenger—so it is the entire grab sampler being developed by the BRE, the journey that is important. We become focused on the former Building Research Establishment. The tests aircraft but the journey from starting and finishing, involve creating a fume event on the ground and round a baggage hall and waiting for your bags to seeing what substances the equipment records. The arrive etcetera. In statistical or any other research the tests may also determine where best to place sampling eVect of confounding must be clarified. equipment on aircraft. Once we have identified eVective equipment, it is intended to sample around Q295 Lord Haskel: On the question of toxic air, we 1,000 flights using more than one sampling device, have had a number of people tell us that they are more than one laboratory to analyse the results and concerned—also the Pilots’ Union has told us— an independent project manager from the academic about fume events on aircraft. What action is the world. Crew will be asked to record whether they government taking to meet these concerns? detected any smells. We shall use the BA 146 and the Jim Fitzpatrick: There are occasional bad smells or Boeing 757, including specific aircraft where fume fume events during flights and these have been events have been reported in the past. We are reported particularly on the Boeing 757 and the BA grateful, if I may say so, for the help of the airlines, 146. Second, some pilots who have experienced these BALPA and the Advisory Committee on Toxicity. events do report a variety of short or long term symptoms or ill health. However, no link has been established between these two facts to a standard Q296 Lord Haskel: That certainly is a very which has convinced any government or regulatory impressive project and I am sure it will throw up a lot authority, bearing in mind that aviation is global. of new information, but meanwhile we have been 3844421013 Page Type [O] 30-11-07 13:08:21 Pag Table: LOENEW PPSysB Unit: PAG3

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17 July 2007 Mrs Dawn Primarolo, Mr Jim Fitzpatrick, Mrs Sandra Webber, Dr Ray Johnston hearing from for instance Dr Sarah Mackenzie Ross pilots to be able to record anything which they think that some pilots are presenting symptoms consistent is appropriate. The fact that there are reports clearly with organophosphate poisoning. Should this indicates that pilots are prepared to come forward aerotoxic syndrome be classified as an occupational and make those reports to the authorities. disease while all this work is going on? Jim Fitzpatrick: My brief says that Sarah Mackenzie Q299 Lord Haskel: You have every confidence in the Ross’s study was a small one without a control group integrity of the CAA statistics? and the subjects came from patients ie, they were not Jim Fitzpatrick: We are confident in the statistics randomly selected. The Committee on Toxicity because of the information I have just given but also arranged for an independent review of it by Professor because there are two other avenues to report if an Robin G Morris, professor of neuropsychology at individual wishes to bypass an employer, which may the Institute of Psychiatry, King’s College Hospital be a natural concern for anybody. One, there have in London. Professor Morris’s report said that the been no air contamination incidents reported by association between flying and neuropsychological flight crew via the individual confidential pathway to abnormality “should be interpreted with great the CAA so, although the procedure exists for people caution because of the small sample used.” He to report it without having to go through their concluded that the study “cannot suggest a link and employer or their line management, no such reports equally it does not rule out a link. In order to have taken place. Because of the reports which are establish a link there is need for a much larger study being received through formal procedures, it tends to taking a randomly selected epidemiological sample. suggest that we are getting reports. Secondly, the There are practical diYculties in designing such a number of air contamination incidents sent to the study.” We are not discounting Sarah Mackenzie confidential Human Factors Incident Reporting Ross’s study but we are saying that we need far more Programme is small, 22 in total to date, nine from evidence upon which to base our conclusions. flight crew, ten from cabin crew and three from others. The programme is seen as an alternative Q297 Lord Haskel: You are not going to classify it reporting approach for an individual to report as an occupational disease? concerns without their employer being involved so Jim Fitzpatrick: I do not think we are in a position to we are confident in the reporting systems. draw conclusions at this stage until we get adequate evidence on which we can make decisions. Q300 Lord Haskel: If your confidence is in the fact that no reports have been received, of course the Q298 Lord Haskel: Another thing that we have been alternative could be true, that they do not know told is that some of the airlines have told pilots not to about the mechanism of reporting and that is why no report these events. In some phases of flight, people reports are received through the alternative say that they are normal. What is the view of the mechanism. government and the regulator about this matter? Jim Fitzpatrick: The fact that the procedures are Jim Fitzpatrick: From the information I have in front there, that they are publicised and that there are of me about the claim of severe under-reporting of reports from cabin crew for other actions and fume events to the CAA, it is our view that the UK activities tends to suggest that both mechanisms are has one of the best aviation safety records in the being used. One can never say that an incident has world and that the CAA’s mandatory occurrence not been reported because that will be a matter of reporting scheme is part of our successful safety individual professional integrity. All kinds of factors regime. The CAA receives approximately 10,000 new may get in the way to prevent someone from reports every year. The definition of a reportable reporting an incident, but we are confident that the occurrence is any incident which endangers or which, evidence and the reports that we are receiving are if not corrected, would endanger an aircraft, its accurate and they do supply us with information occupants or any other person. The EU also now which says that there is a potential problem. We are requires all Member States to have such a scheme not ignoring that problem. We are not ignoring the under Directive EC2003 42 which is essentially based reports. We are spending quite a bit of money to on the UK scheme. The CAA chairman assures the make sure that we can get the equipment to be able to confidentiality of reports and provides that the CAA do the sampling upon which we can analyse the will not take any action, punitive or otherwise, results and determine from those results what the against an individual as a result of a report, except in cause and eVect is, whether it is short term ill health cases of gross negligence. The CAA encourages and or long term problems. We are very much at an early expects employers to act accordingly. We do not stage but we are putting a lot of eVort and resource believe that there is under-reporting. We believe that into addressing this problem because we do there is every encouragement given to professional acknowledge that there is an issue of concern here. 3844421013 Page Type [E] 30-11-07 13:08:21 Pag Table: LOENEW PPSysB Unit: PAG3

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Lord Haskel: I am sure that when you have done all Q303 Earl of Selborne: You see the relevance of my that work there will be a lot of important information question because if you are going to do 1,000 flights which will be very valuable. and if you are going to concentrate on those aircraft which are more susceptible, you would be closer to the one per cent range than the half per cent range. Q301 Chairman: May I return to one of Lord Even then you are only going to get ten events, but Haskel’s questions? We are aware that at least one that is going to be a lot better than five. airline has been telling pilots not to report these Mrs Webber: Absolutely. If it were not for the fact events. Do you not think government should do that we were going to be using the particular target something about this? aircraft, the advice that we have had from the Mrs Webber: There was a parliamentary question. It Committee on Toxicity is that we might have to is better that I give you the answer to that so that we sample 3,000 if we were going to do it completely are consistent. The airline in question was a cargo randomly. By focusing in on airlines which are airline, DHL Air Limited. This was a question asked deemed to have a problem, it enables us to reduce the in March in the House of Commons by Tobias number and therefore, in terms of cost eVectiveness Ellwood, MP, and the answer given was, “The DHL and also the practicalities of getting all these devices instruction referred to has been assessed by a CAA through security and placing them on aircraft and flight operations inspector as part of the full range of explaining to passengers where necessary what they company instructions relating to smoke, fumes and are, it make it all much more practical. air contamination. The instruction was promulgated as follow up information additional to the relevant Q304 Baroness Platt of Writtle: We did have some normal, abnormal and emergency procedures. These evidence, although I do not have it in front of me, include company guidance for the use of oxygen and that it is a feature of short haul and the fact that they masks. The CAA inspector found that the instruction are climbing and have a very short period of cruising was acceptable in that context as part of the overall at one particular height, so they are going up and regime and the operator has taken steps to ensure in coming down. Have you had any evidence of that? training sessions that it must not be interpreted as a Mrs Webber: I heard that. That was Captain Tim dilution of the company’s safety policy with regard to Bamber from BALPA who did say that was his own reporting of incidents of this type.” theory. However, certainly the analysis that the Committee on Toxicity has done has found that, with one of these two aircraft types, the 146 and the 757, Q302 Earl of Selborne: You gave some very the predominance of reports was on the climb. The interesting statistics and I think you said that you other aircraft type was more evenly spread would expect these events to happen in between half throughout the flight so certainly there is some a per cent and one per cent of flights. I think you also evidence that there is more occurrence of fume events said that some types of aircraft were more prone than on the climb. others to this. Does that mean that there are some aircraft where you would expect the incidents to be Q305 Chairman: We have heard from pilots’ unions more often than half to one per cent or is that all types last week that low cost airlines schedule work for of aircraft, this half to one per cent? pilots in such a way that their normal roster is to fly Jim Fitzpatrick: May I ask Mrs Webber if she has the to the maximum permitted number of hours and that statistics to hand in respect of the 146 and the 757s their rest periods are being eroded. What is the and the relationship to the half to one per cent? government and the regulator’s view of this? Mrs Webber: The half per cent is overall and Jim Fitzpatrick: Like all employers in a competitive therefore, yes, there have been higher incidences on environment, airlines naturally seek to maximise the some aircraft types. The Advisory Committee on utilisation of their crews. However, safety is the UK’s Toxicity which is doing a lot of work on this began a top priority in aviation. We have one of the best project about a year ago to evaluate a whole raft of records in the world. We intend to do all we can to information provided by BALPA, but has also gone keep it. The law requires all operators of public beyond that as part of its evaluation and has called transport flights to limit the hours that pilots work for the databases from the CAA and from a number through adherence to a flight times limitation scheme of airlines and has worked out the statistics. This is approved by the CAA. The CAA is working closely where we got the figure from because they have with airlines, including the low cost sector, and has looked at all the databases in existence that they can already identified a number of initiatives such as get hold of. They have found that those aircraft are monitoring the outcome of rostering and training on more prevalent in terms of reports of this than others measures to counter fatigue. The Department for so, yes, that would be higher than half a per cent. Transport and the CAA are keen to discuss this issue 3844421013 Page Type [O] 30-11-07 13:08:21 Pag Table: LOENEW PPSysB Unit: PAG3

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17 July 2007 Mrs Dawn Primarolo, Mr Jim Fitzpatrick, Mrs Sandra Webber, Dr Ray Johnston with BALPA. The Secretary of State wrote to keen to get to the bottom of because, although BALPA on 5 June inviting them to come in to discuss airlines naturally have a duty to the public and to their survey with oYcials, so this is a report that we shareholders to fly, the issue of safety is paramount. are indeed taking seriously. If safety were to be compromised as a result of fatigue, obviously we would need to address that Q306 Chairman: Does the Aviation Health Working seriously. My Secretary of State has written to the Group have an interest in pilots’ fatigue? What are pilots’ union to come in and discuss this item. The you doing about it? Aviation Health Working Group will be prepared to Jim Fitzpatrick: It has not made it a work project so look at it but that will be a matter pending the far, but we are looking at it and obviously at the outcome of the discussions we will have with them meeting that we will have with BALPA they may very shortly. well ask the working group to look at it. We are open to that question. Q308 Chairman: Do you think there is a chance that the government might recommend a revision of the Q307 Lord Haskel: The point that was made when CAA’s CAP 371? we were told about this by BALPA was that by Jim Fitzpatrick: I would not wish to anticipate the working the maximum hours, by the time the pilot outcome of discussions, especially only having been gets into his car and drives himself home, he is a in the job for the past two weeks. To start laying danger to himself. The point was raised that this down rules about operating hours at this stage would should be taken into account because it is as much be a trifle ambitious for a parliamentary under- about pilots’ safety as the passengers’ safety. I secretary. wonder whether you have taken this matter into Chairman: Thank you, Ministers, Mrs Webber and account? Dr Johnston, for coming to talk to us. It was a very Jim Fitzpatrick: We are about to meet with BALPA valuable session. If there is anything else that occurs and I am sure, having raised it with yourselves, they to you, please let us know. It can be still included in will raise it with us. It is something that we are very our inquiry. Thank you very much. 3844421015 Page Type [E] 30-11-07 13:08:21 Pag Table: LOENEW PPSysB Unit: PAG3

74 air travel and health: evidence As part of the Governmentinquiry, response DFT, to DH, the HSE HoL andcommissioned CAA a jointly stage 1 studyE V ects into on the Health ‘ of Possible AircraftEnvironments’. Cabin This study was carriedInstitute out of by Environmental the Health andin published January 2001. Stage 2 of the studywas was submitted carried to out the by AHWG BREin for and July consideration 2001. The studyknowledge investigated of the issues state identified of instudy, the and Stage devised 1 a priorityresearch assessment areas. of The study identifiedfuture 5 research— areas for DVT Cabin Air Quality Transmission of infection Cosmic Radiation Jet lag The Aviation Health Working Groupon first 26 met March 2001 withDH, members CAA from and DFT, HSE. Representativesaviation from industry, the consumer groups andinterested other parties such as medicalparticipate specialists in also meetings. The Aviation Health Unit (AHU),a which focal acts point as for aviationUK, health was issues established in on the 1CAA. December The 2003 Unit in is the theto primary DFT, source DH of and advice industry.Dr The Raymond Head Johnston. of AHU is Memorandum by the Department for Transport The study into “Possible E V ectsAircraft on Cabin Health Environments” of is designedreveal to the main areas ofwhere concern, there and are to significant identify gapsknowledge in base, the with existing a viewfacilitating to further, promoting well-targeted or research. The Government proposes to establishstanding a inter-departmental Aviation Health Working Group (AHWG), chaired bywhich DETR, will meet on a regular basis. House of Lords Select Committee Recommendations—Air Travel and Health A Higher Profile for Health 1.8 We recommend the Government to ensure that concern for passenger andbecomes crew a health firm priority. (Paragraph 8.9) Recommendation Government response Update 3844421015 Page Type [O] 30-11-07 13:08:21 Pag Table: LOENEW PPSysB Unit: PAG3

air travel and health: evidence 75 In the Civil Aviation ActState 2006, for the Transport Secretary is of chargedduty with of “the organising, general carrying outmeasures and for encouraging safeguarding the healthon of board persons aircraft”. The functionsset of out the in CAA section as 3(c)1982 of are the also Civil amended Aviation to Act persons include on the board health aircraft. of DFT and CAA continue toopportunities look to for work internationally andEurope within on suitable issues. Anled example Ideal is Cabin the Environment EU- (ICE)which Project, is looking into thee V ects combined of multiple long-haul travel ataltitudes varying on cabin people of di V erentis ages. co-ordinated This by project BRE. Thethe medical project chair is for Dr Raymondthe Johnston, AHU. Head of The Government shall continue tolike-minded work countries with to try toissues ensure are that on health the internationalDETR aviation has agenda. proposed that theAviation European Conference Civil (ECAC) consider submitting a paper on airICAO travel Assembly and in health autumn at 2001. the The CAA has initiated across-reference research medical project records to held byDivision the on aircrew to theundertaken types during of the flying pilot’s lifetime.then These be will compared to themedical subject’s history subsequent obtained from deathand certificates other sources. This shouldinformation provide about possible links betweenaircraft the cabin environment and subsequent disease. In 2001, DFT presented aAviation paper Health to which ECAC led on toworking the group formation on of Air a Passenger(APHI). Health The Issues aim of theproduce working an group ECAC was manual to ofwhich best was practice, submitted to ICAOform Assembly of in an the information paperManual in covers 2004. services The to passengersmedical (on-board kit, crew training, airportcabin facilities design); and passenger information; and medical incident reporting. Work wascarried also out on how to introduce legal protection 1.9 We recommend the Governmentpursue actively the to strong UK interestcrew in health passenger through and its internationalwith contacts the Joint Aviation AuthoritiesInternational (JAA), Civil the Aviation Organisation (ICAO) and other appropriate organisations, and we urge them all(Paragraph actively 8.10) to promote health. 3844421015 Page Type [E] 30-11-07 13:08:21 Pag Table: LOENEW PPSysB Unit: PAG3

76 air travel and health: evidence See responses to 1.8 and 1.9. The Department for Transport andhave the arranged CAA to visit theSafety European Agency Aviation (EASA), the successorthe body JAA, to in the Autumnprogress to in brief the o Y cials UK on acrossespecially health in issues, relation to cabin air research. On 13 April 2004 theTime) Civil Regulations Aviation 2004 (Working came intotransposing force, the provisions of Council2000/79/EC Directive on the organisation ofof working mobile time workers in civillegislation aviation (see into also UK 1.38). At the same time DFTOccupational set Health up and the Safety Aviation Workingto Group look at certain aspectssafety of in crew the health cabin and environment.chaired The by group the is CAA, withfrom membership both drawn the airlines andrepresentatives, employees and has been instrumentalproducing in guidance material for aircraft operators and others involved inaircraft, the on operation good of health andcabin. safety Employer practice representatives in on the thegroup working have welcomed its workthe as profile having of raised health andorganisations. safety issues within their Under the Air Navigation Orderan flight obligation crew to have inform theinjury, CAA illness of involving personal incapacity for 21 days or for volunteering health professionals (Good Samaritan Law versus insurance coverby provided the airlines). Dr AnnetteUK Ruge at represented recent the meetings. The Government is not complacentof about performance levels in ICAO orrecent JAA, years and has over been inboth the organisations forefront to of improve moves administrative in e Y ciency and combat inertia. Butestablishing negotiations international regulations are byvery their nature complex, requiring flexibilitywillingness and to unite often disparatecan views, mean which that progress isbe not achieved as within rapid a as national might administration. Council Directive 2000/79/EC, which provides for a European Agreement onof the Working Organisation Time of MobileAviation, Workers has in recently Civil been adoptedagreement following between the European socialThe partners. Government is currently consideringimplementation the of this Directive, whichbring should about improvements in therecording monitoring of and the general health of aircrew. In the CAA’s view itwould is find unlikely significant that ill an health AME would in not a a V ect pilot their which medical certification. If a 1.10 We recommend the Unitedother Kingdom governments and to do everythingreduce they inertia can within to the internationalfocused safety- regulatory structures. (Paragraph 8.7) 1.11 We were surprised atby the regulators, lack airlines of and attention— aircrewunions—to trade the health of aircrew.that We there are are aware serious issuesconfidentiality of and medical job security involved. Nevertheless, we recommend that therules, present agreements and attitudes regardingmonitoring the and recording of theof general aircrew, health over and aboveoperate, their should fitness be to reconsidered urgently (Paragraph 3.48). 1.12 In the case ofthe pilots, authorised we medical recommend examiner that, (AME) if evidence finds of significant ill health not necessarily 3844421015 Page Type [O] 30-11-07 13:08:21 Pag Table: LOENEW PPSysB Unit: PAG3

air travel and health: evidence 77 more or pregnancy. In orderrelevant to health capture information all so thatadvice appropriate can be o V ered toside flight of crew, the the medical reverse certificatewith has detailed been information printed advising themthey that should consult the CAAMedical or Examiner their if Aviation aware ofmedical a fitness. decrease An in Aeronautical Circularalso has been issued further expandinginformation this and giving examples ofevents medical and illnesses that should be reported The AHWG worked with DHsubsequently to issued agree as text o Y cial Government advice. This was circulated totravel airlines interests and in other 2001 andDirect was and placed the on DH NHS website2001). (on 30 November Since 2001 the internet hasmain developed method as of the transmitting adviceDH to has travellers. two current articlesinformation containing and advice about DVTwebsite: on a its section in HealthTravellers: Advice http://www.dh.gov.uk/en/ for Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH 4123441 and a more detailed documenttravel-related called DVT Advice which on was lastMarch updated 2007. in http://www.dh.gov.uk/en/ Policyandguidance/Healthandsocialcaretopics/ Bloodsafety/VenousThromboembolismVTE/ DVT/DH 4123480 The Health Protection Agency websiteto has other links government and non-government websites containing travel advice http://www.hpa.org.uk/infections/topics az/ travel/travel advice.htm – – – – pilot needs treatment or advicethey about are a invariably condition referred backgeneral to practitioner their who own can, ifthem necessary, seen have by a specialist.then If he a or pilot she is has unfitCAA’s a to Medical legal fly Department. duty to inform the The AUC has informed theintention Government to of publish its an up-datedFlight version Plan of incorporating, inter alia,expanded an section on health issues.Government The proposes to produce aform standard of words giving advicerisks on associated the with major air health travel.tailored This as advice, appropriate, will beHealth included Advice in for both Travellers andwill Flight be Plan referred and to inissued Travelling by Safely, the a CAA. booklet Itto will airlines also and be other made parties available information wishing on to air give travel andrepresentative health, bodies including of tour operators. a V ecting a pilot’s fitness certification, this should be recorded and reported bothto to the the a V ected CAA person’s and general(Paragraph practitioner. 3.48) Fitness to fly 1.13 The booklets from theHealth Department (DH), of Health Advice forfrom Travellers, the and Air Transport UsersFlight Council Plan, (AUC), should be importanthealth sources information of and advice forpassengers. intending We recommend that priorityto be refining given the advice inany Flight concerns Plan: about “If your you fitness have your to doctor fly, before talk you to bookneeds your to flight”, be which made much8.48). more specific (Paragraph 3844421015 Page Type [E] 30-11-07 13:08:21 Pag Table: LOENEW PPSysB Unit: PAG3

78 air travel and health: evidence It also works in partnershipTravel with Network the and National Centre (NaTHNaC)is which funded by DH. NaTHNaCinformation produces sheets on DVT forprofessionals. travellers http://www.nathnac.org/ and for yellow book/13.htm. Likewise Health Protection Scotland haswebsite a called “Fit for Travel’information which and includes advice about airwww.fitfortravel.nhs.uk/advice/index.htm travel http:// The FCO website www.fco.gov.uk haspromoting a its section Know before youcampaign go including travel the safety advice tofor visit vaccinations your at GP least sixtravelling weeks overseas. before http://www.fco.gov.uk/servlet/ Front?pagename % OpenMarket/Xcelerate/ ShowPage&c % Page&cid 1007029391116 The CAA produces a Travellingpassengers Safely which leaflet is for available viawebsite. the CAA The Travelling Safely leaflet includesaddresses the for website health advice fromThe DH AHU and has FCO. its ownpoint website, for providing enquiries a about focal aviationand health featuring issues FAQs and pertinentThere health were links. approximately 1200 “hits”2007. in May Information for professionals can bethe accessed NaTHNaC at website. http://www.nathnac.org/yellow—book/13.htm. NaTHNaC are funded by DH to provide travel – The CAA agrees that theto inclusion Health of Advice references for Travellers(as and revised) Flight within Plan the Authority’sSafely Travelling leaflet would be aIn helpful the step. light of thecommissioned study into that cabin the health, Government the has examine AHWG the will current range ofwill publications consider and the possibility offurther commissioning study a to advise oninformation how on e V ective air travel andconveyed. health can be best This book was initially intendedrisk—mainly to related cover to disease infection—in destinations abroad. It has sinceto been cover expanded “the traveller” asdestination” well in as more “the detail. The book, which is 1.14 We recommend CAA toSafely revise leaflet, its at Travelling least toHealth cross-refer Advice to for the Travellers revised andWe Flight also Plan. recommend DH, CAAconsider and whether AUC the to combination ofpublications their as three currently conceived bestthe serves travelling public’s information needs (Paragraph 8.49) 1.15 We recommend that DHthe monitor revised the Health use Information of forTravel Overseas to ensure that, withamendments further as additions necessary, and the publication provides the user-friendly authoritative 3844421015 Page Type [O] 30-11-07 13:08:21 Pag Table: LOENEW PPSysB Unit: PAG3

air travel and health: evidence 79 health advice. NaTHNaC took overInformation the for Health Overseas Travel, alsoas referred the to Yellow Book, andThe it Yellow is book now has on been itsof updated website. ways in since a the number firstNew edition chapters in have October been 2001. added,“Medical including considerations for the journey”includes which a section on DVT. The UK and the Europeana Commission World funded Health Organisation (WHO)programme research costing ƒ 2.8million (to which the UK contributed ƒ 1.8million from DFT andfunds) DH to look at theof incidence DVT. and Known mechanisms as theresults WRIGHT of project, this the two-year studydistance showed travel that leads long- to aof small DVT. but The increased risk, risk whichtravel, applies appears to to all be forms predominantly of prolonged the immobility. result A of summary ofpublished results on was the DFT website2005, in together December with a PressAnnex Release—attached B—to at promote understanding ofnature the of the risk andupdated higher its risk web groups. advice DH toThe reflect WRIGHT the phase findings. 1 reportpublished is by due the to WHO be onWRIGHT 28 team June are 2007. seeking The fundingphase for of a the second study, toUK look would at be interventions. sympathetic The tothe contributing scale but of study neededinternational is funding. likely to need DH and BATA (British AirAssociation) Transport commissioned Research Works Limited to conduct a studyof to publicity assess on e V ectiveness DVT. The15 findings October presented 2003 on showed most people were aware issued to all General Practitionersnurses, and is practice in the processDepartment of of being Health. revised by the The Government shares the viewevidence given to in the the Inquiry thatoptions of of the study three methodology major forfurther looking at the issue ofcontrol DVT, study the is proposed likely case- tofeasible. be However, the even only a one study thatlikely of is to this be type large is andembarking expensive. on Before a study onconsider such that a a scale systematic we reviewis of required, the to literature determine fullyalready the been work carried that out, has andfor to further identify research. the gaps information source that is needed by health professionals (Paragraph 8.41) Deep Vein Thrombosis 1.16 It is imperative thatdata the on current deep paucity vein of thrombosisremedied (DVT) and be we recommend thatepidemiological an research programme of thecontrol case- type be commissioned bypracticable DH (Paragraph as 6.25). soon as 3844421015 Page Type [E] 30-11-07 13:08:21 Pag Table: LOENEW PPSysB Unit: PAG3

80 air travel and health: evidence but depth of knowledge varied.were Health subsequently messages reviewed and revisednecessary. where One output of the studyaspirin was which about DH the followed use up of at in quantifying a the study aspirin aimed usagelong-haul amongst aircraft UK passengers. The “Synovate” report was published on DFTin and April DH 2006. websites Airlines provide information to passengerstheir on long haul flights throughflight websites, magazines and and/or in- films. Information is also available fromsources a eg variety supermarket of magazines. The Chief Medical O Y cer has2007) recently published (April a report onVTE the in prevention hospitalised of patients (Reportindependent of expert the working group onprevention the of venous thromboembolism (VTE) in hospitalised patients). The expertgroup working Ministers asked to be set up and report to Although it is for othersrecommendation, to the respond Government to accepts this allboxes the contained in the Reportguidance, as pending useful further interim evidence. The Government endorses the guidance inand Boxes 3 2 (pages 46 andsome 48 rearrangement of to the give Report), an subjectrelative indication to priorities. of The interim precautionary and preventative advice concerning air travel andpresented DVT, in as Box 4, isthose helpful. considered However, as for “substantial risk”,recommends DH that medical advice shouldobtained. be Many airlines had taken stepsinformation to made enhance available the to passengersto prior publication of the recommendations.BATA All member airlines are nowthe compliant recommendations with with regard toalso DVT; provide many extensive information ontravel a health range issues. of The WHO research programme referredabove to should make a significanttowards contribution clarifying the prevalence ofShould DVT. the outcome of researchincreased reveal likelihood an of DVT fromof a transport wide modes, range or thatwidespread the that condition it is requires so action as a general 1.17 As an interim measuredevelopment pending of the more authoritative guidance,recommend we airlines, their agents andconsumer others interests with to repackage theindicative summary and precautionary advice onBox DVT 4, in together with theon summary predisposing information and risk factors3, in and Boxes make 2 it and widelypublic. available This to will the enable general thoseto who other have advice no to access makeabout preliminary their decisions travel and the(Paragraph risk 6.29). of DVT 1.18 We recommend the Governmenttackling to DVT consider on a widerindeed, travel-related as front a or, general public(Paragraph health 6.30). matter 3844421015 Page Type [O] 30-11-07 13:08:21 Pag Table: LOENEW PPSysB Unit: PAG3

air travel and health: evidence 81 CMO on the subject tookconsider the VTE opportunity in to the widertravel. context, The including report is availablewww.dh.gov.uk/en/Publicationsandstatistics/ on line http:// Publications/PublicationsPolicyAndGuidance/ DH—073944 In Ministerial statements and Government published material, we do not“economy-class use syndrome”, the and term take appropriate opportunities to advise against it. In-flight information for long-haul passengersnow is commonly provided by airlines. The research report EC1279 “Anthropometric Study to Update Minimum AircraftStandards”, Seating prepared by ICE ErgonomicsJoint for Aviation the Authorities (JAA), was published health matter, then such actionconsidered. will be Although this recommendation is notto addressed the Government, we fullymisleading agree term that should this not beflight-related used DVT. in DH relation is to currentlyhow discussing best to circulate thisprofessionals. message to health The Government agrees that encouraging passengers to avoid prolonged immobilitykey is factor a in any strategyDVT. to But reduce the the Government risks is of need conscious to of word the any newthat instructions passengers carefully, who so spend moreseats time as out a of result their ofexposed the to instructions unnecessary are risk not fromassociated injuries with unexpected movement ofaircraft. the The CAA-funded research study, onthe behalf JAA, of is considering theaircraft relationship seat between dimensions and passengerwork sizes. looks The at the changing size of the European 1.19 The term “economy-class syndrome”, widely used to refer tomisconceived flight-related in DVT, suggesting is that theDVT possibility need of not concern businesstravellers—or and those first using class other air formsdistance of transport. long- We recommend thatprofessionals health and others stop usingmisleading the term seriously “economy-class syndrome”. “Flight-related DVT” or “traveller’s thrombosis” would be more appropriate (Paragraph 6.23). 1.20 In relation to airprecautionary travel, principle and used applying in the otherhealth fields risks where are considered possiblewell but defined are or not quantified, therewhich are could measures be taken toand improve alleviate information concerns about flyingand and to DVT, encourage preventative activities.recommend We that airlines and theirreappraise associates their current practices innot relation only to the provision ofpassengers information but for also the designcabin of service the procedures. cabin We and alsothe recommend Government, aviation regulators, trade groups and consumer representatives towhat consider action they should takepoints in (Paragraph relation 6.31 to and these 6.32) Seating 1.21 We were pleased toresearch hear into about people’s new size CAA andmobility the after reduction long in flights toemergency ensure evacuation that requirements the are in line 3844421015 Page Type [E] 30-11-07 13:08:21 Pag Table: LOENEW PPSysB Unit: PAG3

82 air travel and health: evidence in July 2001. The recommendationsresearch in report, the specifically the proposalsnew for minimum dimensions between seats,presented were to the JAA CabinGroup Safety at Steering the time ofreport. the The publication increased of dimensions the comparedthe to existing UK requirements wouldmodification require of aircraft with significant commercial implications for a V ected operators. Implementation would therefore be necessaryat on least a Europe wideassumed basis. responsibility EASA for has large since aircraft certification and rulemaking. At the advent of EASAprovisions the of UK Regulation used (EC) the 1592/200210 Article (1) to maintain theas UK a seat unique, spacing mandatory standards requirementThis in Article the provides UK. for areact Member to State a to safety problem,result if of that an problem inadequate is level the from of application safety of resulting the Regulation.caused This EASA action to consider seriouslyseat the spacing issue standards. of After deliberationconcluded EASA that the issue wasairworthiness, not but one of of operations andthe instructed CAA to remove thereplace Article it 10 with (1) an item operating and and rule. is This recorded was as done CivilCAP Aviation 747, Publication Generic Requirement No.allowing 2, CAA thereby to apply itsstandards. previous seat spacing Although the seat-spacing issue ison not the currently EASA rulemaking programme,need it to will be addressed byresponsibilities EASA for once regulation it of assumes operations, expected in early 2008. Although there was originally an intent to population but also includes aDVT review research. of recent EASA’s draft rule making programme2005–2007 for recognises that the issuespacing of needs seat to be investigated. with modern circumstances. Given changes over the years in the lengthages of and flights health and states in of thethem, people sizes, we undertaking recommend that thiscompleted research urgently be (paragraph 3.51). 3844421015 Page Type [O] 30-11-07 13:08:21 Pag Table: LOENEW PPSysB Unit: PAG3

air travel and health: evidence 83 include consideration of the e V ectson of mobility long (ability flights to leavethe the aisle), seat this and was move not to phase included of in the the research. completed Itincluded would in need any to future be researchsupport update new to rulemaking. Airline seat-pitch data is commonlyonline available and should be availablerequest. from airlines on See item 1.21 BRE (ex-Building Research Establishment), acting for DFT and DH,ranging, conducted EC-funded a research wide programme, Cabinair, into the health andinvolved comfort in issues cabin air quality.extended The to work include was measurements onaircraft older types and was carried2002 out and between October July 2003. Titledquality the in “Study the of aircraft air cabin”the it DFT was website published in on 2004. The CAA raised the subjectthe of existing a airworthiness need requirements to on review ventilation and cabin air qualityJAA in working the group. applicable EASA hasresponsibility since in assumed this area. Intogether 2003, with the DGAC CAA, France, produceddetailing a the paper range of issues that needed to be The CAA-funded research study (andsubsequent any follow-on study) will provide Government with the information necessaryreview to current regulations on seatlight spacing. of In the the study DETRconsider and the the scope CAA for will developing also definitions unambiguous for seat dimensions forinforming use passengers in of the seatavailable size on and a space flight. The Government accepts this recommendation. The CAA will write toreview the of JAA airworthiness requesting requirements a and guidance material relating to cabinrequirements air for supply passengers. See also the Ideal Cabin(ICE—see Environment Item Project 1.9). 1.22 To facilitate passengers’ choicewe of recommend seating, CAA to useto its develop current an research unambiguous setseat of dimensions. definitions The for key issuesminimum are: size the of seat takingconsiderations; account accommodation of of health passengers above average size; and properseat-space allowance reductions for from the seatreclined, in material front in being seat-back pocketsdown and tables fold- (Paragraph 6.49) Ventilation 1.23 For the main purposecertification, of JAA airworthiness currently has noair specific supply cabin requirements for passengers,US and Federal the Aviation Administration (FAA) requirement is seen by manufacturerscases, as, impossible in or some impracticable. Becausethe of intrinsic importance of theclarify matter matters and which also cause to greatwe public recommend concern, the Government, CAAto and find JAA a practicable waypossible forward (Paragraph as 3.36). soon as 3844421015 Page Type [E] 30-11-07 13:08:21 Pag Table: LOENEW PPSysB Unit: PAG3

84 air travel and health: evidence addressed and the proposed constitutionterms and of reference of anworking authority/industry group. This was takenconsideration to of EASA further for action. EASAintends now to issue an A-NPAProposed (Advance Amendment) Notice based of on theseto proposals assess support for furtherin action. the The EASA action rulemaking is workthe programme second for half of 2007. Material on cabin air hasnumber been of published websites, on including; a CAA http://www.caa.co.uk/ default.aspx?catid % 3&pagetype 90& pageid % 1345 British Airways http://www.britishairways.com/ travel/healthcabair/public/en gb Thomas Cook http:// www.thomascookairlines.co.uk/ Your Wellbeing in the Air.htm DFT is preparing an in-flightresearch cabin project—see air paragraph sampling 11 ofDFT the DH joint CAA memorandum to the Committee. – – This recommendation appears to bemisunderstanding based over on the a JAA’s requirement for ventilation of the flightGovernment deck. notes The that this requirementnot does specify the exclusive useflight of deck. fresh air on the Both aircraft manufacturers and airlinesmade have information on cabin airfor quality example available, in publications andThis on information websites. is also madeto readily the available media, who exercisewhich the sources right of to information choose they use. The airlines and aircraft manufacturerswelcome would the availability of suitableto technology allow routine sampling anddescribed. spot-sampling Equipment as currently available requires careful setting up andcalibration, rigorous and is therefore notroutine suitable use. for 1.24 We recommend the GovernmentJAA to to urge reconsider its requirementof for the ventilation flight deck with5.17). only fresh air (Paragraph Air Quality 1.25 Passengers’ perception of generalquality cabin is air one of theassessment key of factors the in flight their experienceWe as recommend a that whole. airlines collect,use record at and least some ofdata the being basic continuously cabin monitored, environment notgive only authoritative to substance to theircommon refutation allegations, of but also tobasis provide for a public better confidence in5.49) these matters.(Para 1.26 We recommend airlines toand carry inexpensive out cabin simple atmosphere sampling programmes from time to time,provision and for to spot-sample make collection inof the unusual case circumstances. (Paragraph 5.50) 3844421015 Page Type [O] 30-11-07 13:08:21 Pag Table: LOENEW PPSysB Unit: PAG3

air travel and health: evidence 85 In 2004, the ASHRAE* SPC161Pfinalised committee a proposed standard forquality cabin on air commercial aircraft inwhich the went USA, out for consultation,which, as amendments a were result made, of andredistributed it for has further been consultation. Itdiscussed is at being the forthcoming ASHRAE Conference in Long Beach, 23–27 June 2007. AHU attended the ASHRAE conferenceQuebec in in June, 2006. Thesubject CAA of raised a the need toairworthiness review requirements the on existing ventilation and cabin air quality in thegroup. applicable JAA working There is a European pre-standard,ASD-STAN* prEN4618. prepared a standard (therepresented CAA on was the drafting committee)was which voted on and acceptedThe by standard all was Member published States. inAt September present, 2004. it is theused only in international Europe. standard Users includeintended Airbus. to It make is this standard(SEN), mandatory in 2006–07. *ASD-STAN establishes, develops and maintains standards requested by theaerospace European industry. It is wellEuropean recognised body as for the the developmentaerospace of standards global by the International Aerospace Quality Group (IAQG). See also response to 1.23 The Air Navigation Order 2005Operation PART of 5 Aircraft Item 76(2)person states shall that: not “ smoke A inan any aircraft compartment registered of in thesmoking UK is at prohibited a in time that when compartment by a The Government accepts this recommendation. Depending upon the results ofwork, the the ASHRAE* CAA will considerquality whether standards cabin should air be extendedthose beyond for carbon dioxide, carbonozone. monoxide and *American Society of Heating, RefrigeratingAir-Conditioning and Engineers The current status of theis ICAO appropriate recommendation in that itwho allows wish those to countries ban smokingallowing to those do countries so, which while prefersuch to choices leave to the airlines to do so. 1.27 We welcome the ASHRAE work on cabin air quality standards and recommendindustry the to support and encouragecompletion its and timely promulgation. We recommend that, in the light ofconsider the extending outcome, cabin regulators air qualitybeyond standards those for carbon dioxide,monoxide carbon and ozone for whichprovide they (Paragraph already 5.51). 1.28 We recommend the GovernmentICAO to to urge upgrade the smokingrecommendation ban to a formal requirementMember on States its in relation to(paragraph all 4.31). flights Pending a formal ban, we 3844421015 Page Type [E] 30-11-07 13:08:21 Pag Table: LOENEW PPSysB Unit: PAG3

86 air travel and health: evidence notice to that e V ect exhibitedthe by commander or of on the behalf aircraft”. of No known UK registered airlinesmoking permits on board its aircraftthat and virtually we no understand airline registeredoperates abroad into that the United KingdomDH does will either. keep the situationreview, with and aircraft if under smoking onpermitted commercial in aircraft the is future, powersregulatory exist provision to to make protect passengerssecond-hand from smoke. The current understanding is thatapplies this on issue routes only close toplumes the are poles sometimes where reported. ozone Themajority vast of BATA members’ long-haulequipped fleets with are ozone converters, includingand BA Virgin Atlantic, the predominantcarriers. long-haul Boeing 747 and Airbusare A330 fitted, aircraft but most BoeingThe 767 charter aircraft airlines are operate not. aA330 mix aircraft of on 767 long-haul and andapproaching one Boeing of to these see is ifcan ozone be converters retro-fitted to its existing fleet. There are no airworthiness requirementsindividual for ventilation outlets for passengers. Individual air nozzles are notfitted now on universally newer aircraft andfrom have the to manufacturers be at requested extra cost. Virtually all passengers flying tonow or do from so the on UK abanned. flight We on would which be smoking reluctant is worldwide to ban press in for ICAO a whenimpact the on practical passengers travelling toUK and would from be the so limited. This recommendation is for airlinesbut to the consider, Government notes thatproposal a is similar currently on thebetween table airline in representative discussions organisations and passenger groups on a possibleon voluntary passenger charter rights in Europe,European following Commission’s the Communication on Air Passenger Rights of July 2000. All BATA member airlines operatingroutes long-haul have fitted or areto fitting all ozone long-haul converters aircraft. Aircraft ventilation systems are designedprovide to e V ective ventilation air flowspassengers. for The all installation of ‘individual’nozzles air is not an issueshould of remain relevance an to option health for and determine. the airline to recommend those airlines which still permit in- flight smoking to complete thevoluntary ban basis. on a Where in-flight smoking may stillwe be recommend permitted, that airlines andshould their actively agents make this clearpassengers to prior intending to ticket purchase.4.31) (Paragraph 1.29 To minimise potential healthwhen problems aircraft fly through ozonerecommend plumes, airlines we to fit ozonetheir converters aircraft to used on routescome where into they contact may with such4.47) plumes. (Paragraph 1.30 We recommend airlines reviewtheir and cabin modify design considerations tonozzles include under [air personal control]. (Paragraph 5.40) 3844421015 Page Type [O] 30-11-07 13:08:21 Pag Table: LOENEW PPSysB Unit: PAG3

air travel and health: evidence 87 The National Travel Health Network(NaTHNaC) and is Centre funded by theclinical DH standards to in promote travel medicine.advice General for travellers is onat the http://www.nathnac.org/yellow book/13.htm. NaTHNaC website This site is regularly updated,steering and committee there comprising is DH, a Health Protection Agency and other experts.works NaTHNaC closely with FCO andto the review travel guidance industry, and toinformation provide on up current to issues. date The UK Government has aadvice policy at on Phases travel 3-6 ofwhich a is pandemic in influenza line withabove WHO will advice, be The updated websites aspandemic appropriate advances. as any The FCO site at http://www.fco.gov.uk/servlet/ Front?pagename % OpenMarket/Xcelerate/ ShowPage&c % Page&cid 1115137377255 already advises British Nationals overseasthey that should take personal responsibilityhealth for during their a pandemic. ICAO Assembly Resolution A35-12, Protection of the health of passengersprevention and of crews the and spread ofdisease communicable through international travel requestsCouncil, the inter alia, to reviewand existing Recommended Standards Practices (SARPs) related to – DH will be considering howdissemination to of broaden health the information for intending airline passengers, stressing the importance of individual responsibilities. Aircraft on the ground arewith normally ventilation provided via either theUnit Auxiliary or Power ground power. The Government would be reluctantobligations to on impose UK carriers unilaterallyof because the impact such actioninternational could competitiveness. have The on Government their hopes that ICAO will berecommendations able for to Member agree States on to follow Transmission of Infection 1.31 We recommend the Government and airlines to do more topassengers dissuade from intending flying while theyinfect are others. likely This to could bea further reminder reinforced that by boarding maywho be are denied obviously to infectious those (Paragraph 7.33) 1.32 To reduce cross-infection risks,recommend we airlines to ensure theypolicies have for suitable occasions when aircraftpassengers with on board have toground be for held long on periods the withoutventilation. suitable (Para 7.22) 1.33 We recommend the Governmentrequiring to UK consider airlines and theirall agents aircraft to passenger retain information whichuseful could in be tracing contacts formonths a after minimum all of flights, three andshould that seek the to Government extend this requirement 3844421015 Page Type [E] 30-11-07 13:08:21 Pag Table: LOENEW PPSysB Unit: PAG3

88 air travel and health: evidence passenger and crew health. ICAOdevelop is and keen update to its SARPs,with aligning the them new IHR. ICAOthat Secretariat a proposes new Recommended Practiceregarding be the included, use of afor “Passenger use Locator by Card” air transportsuspected operators case in or the outbreak case of ofdisease. a a The communicable card has beenthe developed International jointly Air by Transport Association (IATA) and the World Health(WHO), Organization and encourages compliance with23 Article (1) of the International(2005) Health which Regulations states: “Subject tointernational applicable agreements and relevant articlesthese of Regulations, a State Partypublic may health require purposes, for on arrival(a) or with departure: regard to travellers:concerning (i) the information traveller’s destination sotraveller that may the be contacted; (ii)concerning information the traveller’s itinerary tothere ascertain was if any travel inor or other near possible an contacts a V ected with area contamination infection prior or to arrival.” The International Health Regulations 2005agreed were globally and came into2007. force They on provide 15 a June frameworkcomprehensive for response a to the risksdisease of and infectious to chemical andcontamination. radiological The WHO issued thein 2nd January edition 2006 of AirGuidelines travel for and Prevention tuberculosis. and Control .found It on: can be http:// whqlibdoc.who.int/hq/2006/ WHO HTM TB 2006.363 eng.pdf – up with their respective airlinesauthorities, and and public that IATA willits consider recommended refining practice on thepassengers carriage with of infectious diseases. Interm the another longer possible means ofaction international may be for theRegulations WHO to International be Health amended totuberculosis. include The data collected for marketis research not purposes intended or appropriatecontact for tracing. post-flight In accordance with the principles internationally (Paragraph 7.40). 1.34 From time to time,representative airlines bodies and review their the passengercollected data for marketing and other analytical 3844421015 Page Type [O] 30-11-07 13:08:21 Pag Table: LOENEW PPSysB Unit: PAG3

air travel and health: evidence 89 The great majority of aircraftfitted capable with of filters being are equippedfiltration. with HEPA There are no airworthiness requirementsinstall to filters of any kindMost in aircraft recirculation do systems. have themThe but grade some of do filter not. usedthough is it a is customer almost option, aparticularly universal on standard larger now, airliners, tofilters. have However HEPA this is atmanufacturer the and discretion customer. of Any the movemandate to the installation of HEPAneed filters to would originate from a health aspect. The Aviation Occupational Health andWorking Safety Group is looking atIn this. relation to the EuropeanEC Directive Physical 2003/10/ Agents (Noise) Directive, implemented in the UK by the new Control of of the Data Protection legislation,to data support intended post-flight contact tracingcollected should for be that express purpose. Aircraft filtration units are operatedin and accordance serviced with the manufacturer’sand design operating specifications. This ensuresthe that filters perform to thethroughout specified their standard period of installation. The Government accepts that thefiltration standard is of a key contributorpotential to for minimising cross-infection the in aircraftcirculatory using ventilation. re- The vast majoritypassengers of flying on UK aircraftHEPA will standard experience filtration, but thecontinue AHWG to will promote the usefiltration of on HEPA those standard aircraft whereare such not standards achieved. The cost of such aconsiderable measure and, would in be the absencehazard, of unjustifiable. a Passengers noise who wishearplugs to may use choose to purchasewhich a suits product them. The CAA recognises that cockpitcause noise damage could to hearing, althoughunusual it to is ground very a pilothearing permanently is because su Y ciently impaired toflying. preclude We safe understand that British Airways have purposes. In doing so we recommend they also consider improving such data (orensuring at greater least standardisation) to helpthe meet potential needs of post-flight(Paragraph contact 7.41) tracing. Filtration 1.35 We recommend the industryreview as and a substantially whole improve to overallservice in- performance monitoring of filters. (Paragraph 7.24) 1.36 To minimise the riskare of clear cross-infection, that we it shouldthe be, Government and and we regulators recommend tofiltration make to best HEPA standardsre-circulatory mandatory systems in (Paragraph 7.26) Noise 1.37 We recommend airlines toinexpensive extend courtesy the of o V ering freeall earplugs passengers. to (Paragraph 6.55) 1.38 The British Airline Pilots(BALPA) Association made the point onthat, behalf although of cockpit pilots background noisewithin is acceptable limits, the additioncommunication of noise radio can cause the noise at the 3844421015 Page Type [E] 30-11-07 13:08:21 Pag Table: LOENEW PPSysB Unit: PAG3

90 air travel and health: evidence Noise at Work Regulations 2005the (SI exemption 2005/1643), in relation toremoved. aircraft These was Regulations are enforcedHSE—The by HSE the guidance on the(L108 Regulations Controlling Noise at Work)clarify goes at on paragraph to 25 thatRegulations ‘the apply Noise to aircraft inBritish flight soil’—although over in relation tocabin on noise board it is likelyUnderstanding that between the the Memorandum CAA of andwould HSE be taken into accountduplication to of avoid enforcement e V ort. The inter-relationship between health andbeing, well- including stress, is part(see of Item the 1.9). ICE project The British Airways and NHSgive Direct advice websites on jet lag. The Head of the AHUthree carried major out British research airlines with tooutcomes assess of the defibrillator use. Universally,success the rate was low; the likely reason for this investigated noise in the cockpit,they and and as other a airlines result haveattenuating introduced headsets. noise- This is an“duty example of of care” the of antakes employer, the and view the that CAA thatresponsibility is for where change the rests. primary However,AHWG the will investigate this matterif further necessary, and, consider research intothe noise cockpit. levels in The scoping study, which isundertaken, currently will being assess any existingcombined research e V ects on and, if thererecommend is the a commissioning need, of further work. Advice and information on themeridian e V ects flight of are trans- provided byairlines. a However, number the of e V ects andbetween solutions individuals vary and the passengersmay on have flights originated from di V erentArrangements time for zones. meals, entertainment etctherefore must reflect the preferences ofof the passengers, majority as indicated byand market customer research feedback. Any proposal to enhance therespect minimum of level medical in kits andany equipment, associated including increase in medicalcrew/cabin training sta V , for would require re-negotiation ear to exceed levels at which hearing protection would be required by lawexempt if from flight-decks the were Noise not atthis Work may Regulations. have As both healthimplications, and we wider recommend safety CAA andHealth the and Safety Executive (HSE)the to matter investigate further (Paragraph 6.57). Stress 1.39 Noting the inter-relationship between comfort and stress and health,scope together for with combined the adverse e V ectenvironmental with factors, other we recommend that, when investigations are conducted intoimpact the of any particular environmentalhealth factor or on wellbeing, the possibilitye V ects of be combined given appropriate attention6.63) (Paragraph 1.40 We recommend airlines toarrangements review for their the timing ofsleep refreshments periods and on long-haul flightsmind, with and jet-lag also in to adviseand passengers in-flight at about booking appropriate measureswith to the deal e V ects. (Paragraph 6.65) In Flight medical emergencies 1.41 Bearing in mind therange greater of numbers people and travelling bythe air, Government we to recommend upgrade theminimum required provision by UK carriers for medical 3844421015 Page Type [O] 30-11-07 13:08:21 Pag Table: LOENEW PPSysB Unit: PAG3

air travel and health: evidence 91 being a lower prevalence ofrhythm treatable in heart airline passengers (approximately 30%) compared to that seenlarge in (approximately the 70%). population These at datanot would support mandating defibrillators atin this time. point But we doin not the expect common to practice see for anycarry long-haul change them. flights to We have already mentioned (seeareas item where 1.8) research three e V ort hasDVT, been potential focused; cabin air contamination, ICE. In relation to point (f)international There studies has of been the a health rangeflight of of crew, cabin including and a Europeanmortality/cancer study incidence of among flight and cabin crew and NIOSH (NationalOccupational Institute Safety for and Health) studiesattendant of fertility/ flight pregnancy outcomes. The only consistently reported adverse health outcome has been a highermelanoma incidence amongst of flight crew (which,thought, it may is be related to lifestyle factors). Dr Sally Evans, the CAA’sis Chief currently Medical undertaking O Y cer a study,with in the conjunction London School ofTropical Hygiene Medicine, and into the mortalityincidence and of cancer commercial aircrew andControl Air O Y cers Tra Y c (ATCOs), comparing thewith risks that of the generalage, population, sex matched and for socio-economic group.began The in study 1997 and preliminary results are being with JAA Member States. UKforefront airlines of are ensuring at high the standardswith for medical dealing emergencies—for instance, most UK long-haul carriers now ensuredefibrillators in-flight are carried as standard.Government The recognises the importance of spreading good practice, and thisforward will in be the taken AHWG. Most UK operators of long-haulsubscribe aircraft to do such a service. The Government shares the viewgaps that in there current are knowledge ofrelated health to issues air travel. StageGovernment’s II current of study the will assessexisting the knowledge base across aand range recommend of where issues further researchbest would targeted. be As regards the specific areasCommittee: identified by the (a) The Government envisagescontrol initiating type a study case- once Stagestudy II is of complete; its current (b) A case-control type studysome of way DVT to should providing go detailedinformation demographic on air travel whichuse may in also assessing be levels of ofhealth risk areas. in The a AHWG number will of findings consider of the research into DVTprovide insofar information as on they demographic di V erences in levels of risk andinformation consider is whether relevant this to otherFurther health research issues. maybe necessary. (c) Stage II of theexisting study research will on now air assess quality, the what and further recommend research is needed. emergencies to current “best practice” levels in relation to both crew trainingemergency and kits. medical The latter shouldautomatic include external defibrillators (AEDs) onleast at long-haul aircraft (paragraph. Furthermore, we recommend CAA to worksecure through similar JAA improvements to across Europe (Paragraph 7.77). 1.42 We recommend all long-haulconsider airlines engaging to contracted ground based expert medical services. Research 1.43 Our Inquiry has alreadymajor shown gaps where in the knowledge arethe and Government we to recommend commission researchfollowing into matters the as the highest(a) priority: the epidemiology of DVT,type by study; a case-control (b) the demography of airtypes travellers and and frequency the of travel(c) undertaken; real time monitoring ofaspects air of quality the and cabin other environment,establishing with new a and view clear to regulatorypassenger minima cabin for ventilation; (d) testing, with the latesttechnology, non-invasive blood oxygen levels acrossspectrum the of whole air travellers, toderived validate from conclusions data on young(e)exploration healthy of adults; the ways di V erentaircraft aspects cabin of environment the may interact, particularly on those in lessand than average health; (f) extracting maximum value fromimproved available medical and records of aircrewany concerning long-term e V ects from exposureaircraft to cabin the environment (Paragraph 9.3) 3844421015 Page Type [E] 30-11-07 13:08:21 Pag Table: LOENEW PPSysB Unit: PAG3

92 air travel and health: evidence prepared for publication. The studymore will valid become with time, asdevelop more cancers of or the die. cohort As mentioned, the internet hashealth a information wealth from of airlines travel and Government agencies. On (d) there have beenissue no in inquiries last about few this years.in We specialist assume diving this websites. is covered (d) The research, which isquality, envisaged will on give air consideration tothe the e V ect need of to varying test bloodthe oxygen whole levels spectrum across of airwork travellers. on Also, deep the vein thrombosisconsideration will to give aspects that areaircraft specific cabin to environment, the such asoxygen reduced levels, if the scopingcommissioned study reveals which that we such have workbeen has carried not out. (e) the Government recognises thataspects di V erent of the cabin environmentcumulative may e V ects have on certain passengersconsider and this will recommendation in theresults light emerging of from Stage IIstudy; of and its current (f) the CAA has initiatedcross-reference a aircrew research medical project records to totypes the of flying undertaken andsubsequent the medical subject’s history. The AHWG will look atinformation the and provision consider of whether specific research is required in ordere V ective to way establish to the ensure most healthreaches information passengers. The Working Groupalso will monitor the information givenand by other airlines parties to ensureneeds that of this passengers. meets As the regardsrecommendations the for the provision ofinformation: specific (a) Refinement of definitions ofawait seat the pitch conclusion must of theresearch CAA-funded described above; (b) whilst most airlines allowbook passengers seats, to including pre- those withthe extra Government leg-room, accepts that information about Information for passengers 1.44 We recommend the Governmentairlines to and require their agents toinformation provide for more passengers at thebooking time on: of (a) the size of seatunambiguous that standardised is definitions; on o V er, using (b) options for pre-booking seats,those particularly with extra leg-room; (c) whether smoking will beflight permitted in on question; the (d) the need for sub-aquathe divers e V ects to of ensure any that recentadditional diving hazard will when not they create fly; an (e) the need for intendingthemselves passengers that to they satisfy are generallyonly fit for to their fly—not own health (particularly in relation 3844421015 Page Type [O] 30-11-07 13:08:21 Pag Table: LOENEW PPSysB Unit: PAG3

air travel and health: evidence 93 Government is not aware ofof a people general flying problem while unfit.people A who bigger need problem medical is treatmentwho abroad are and not insured. Thisby has FCO been and highlighted Treasury’s recentinsurance. review Concerns of over travel possible medicalare costs likely to encourage peopleconditions with to medical seek advice before travelling. Airlines are making positive e V ortsaccurate to and provide user friendly information.example, For Monarch provide information onin DVT their in-flight magazine asflight well entertainment as videos. on the in- this facility could be moreand, widely through disseminated the AHWG, willto encourage o V er airlines this information more(c) e V ectively; this proposal is currentlyconsideration under in active discussions in Europe; (d) whilst not underplaying thedivers, risks it to would sub-aqua appear disproportionaterequire to all airlines to provideall this passengers. information The to Government willthis consider issue in the Aviationwith Health a Working view Group to pursuingrelevant the representative matter organisations; with the (e) and (f) the informationbooklet contained “Health in Advice the for Travellers”available is via the DH internetCommunications web Division site. are DH currently exploring ways in which widertravel health- advice related might be providedweb through site, the and DH also howwith links NHS might Direct be and developed NHS Direct on-line. Although doctors are unlikely topriority see to it display as general a information high travel on and air health, other thanmay in be travel that clinics, such it informationin could a be leaflet, provided or aspatients part while of their a travel questionnaire needs issuedassessed. are to DH being will consider thisreport further to and the AHWG. The Government is aware thatactively UK considering, airlines and are in severalalready cases introduced, have means of passingheath on information relevant to on-board passengers,not and of is the view thatthis regulation stage. is But necessary through at themonitor AHWG the it e V ectiveness will of theo V ered health to briefing passengers and take whatever further to DVT) but also for that of others; and (f) in the case ofto long-haul deal passengers, with measures the e V ects of jet-lag (Paragraph 9.5) 1.45 The importance of fitnessgiven to suitable fly prominence. needs We to recommend be at that, every ticket sale pointsurgery, and there in should every be doctor’s aasking small intending display passengers, card “Are youTo fit help to them fly?” find theshort answer, and this user-friendly could note o V er of a (Paragraph guidance 9.6). 1.46 Passengers need to beand reminded in-flight on about boarding the simpleminimise measures any that risk of flight-relatedthe DVT, simple and measures of to alleviatepressure head changes pain on from take-o V andrecommend landing. the We Government to requireto airlines provide, immediately before take-o V ,briefing a comparable health to the already required 3844421015 Page Type [E] 30-11-07 13:08:21 Pag Table: LOENEW PPSysB Unit: PAG3

94 air travel and health: evidence http://www.silsoe. cranfield.ac.uk/ ieh/pdf/w5.pdf http://www.dft. gov.uk/pgr/ aviation/hci/hacc/study/studyof possiblee V ectson heal2959 http://www.dft.gov.uk/pgr/ aviation/hci/hacc/study/studyof possiblee V ectson heal2960 This recommendation arose out ofcomments general about how airlines treatedIn passengers. terms of specific complaintslimitations seating came and in space for adverse8.54) criticism (para The Air Transport Users Councilnoted (AUC) that has while many passengersabout do stu V y complain cabin air, uncomfortableit seating, is etc often an add-ondoes to not another get complaint counted. and AUC so complaints has about had uncomfortable 206 seating/seat specific pitch since April 2002 whennumbers. it This started compares recording with aroundtotal 10,000 complaints in the singlemainly year about 2005–06, delays, cancellations and mishandled baggage. DFT (DETR) DFT (DETR) DFT (DETR), DH, CAA & HSE. and Health *Medical Research Council MRC Institute for Environment and Health: Terry Brown, Lesley Rushton, Linda Shuker, Alex Capleton, Jane Stevens and Fiona Warren BRE: John Palmer, Principal Consultant Gary Raw, Centre Director Claire Aizlewood, Sen Consultant Ruth Hamilton, BRE Associate Ken Collins, BRE Associate MRC* Institute for Environment steps may be necessary. UK airlines carry millions ofIn satisfied addition, customers. the vast majorityhandled of e Y ciently complaints and are to thesatisfaction. customers’ All BATA member airlinessigned have up to the Europeancommitment voluntary on Air Passenger Rights.other Amongst things in this fourteenairlines point have document, committed themselves toresolution timely of complaints. Some complainants start with an expectation ofupgrade financial rewards /ticket/ that are inappropriatecannot/ and should not be met.indicate Where in complainants their letter thatlegal they action, are they considering should reasonablyairline’s expect legal the / insurance advisers to be involved. e V ects on health, comfort and safety of aircraft cabin environments A Consultation On The Possible E V ects on Health, Comfort and Safety of Aircraft Cabin Environments—Final Report (Study on the possible e V ectshealth on of aircraft cabin environments—Stage I) Study of Possible E V ects on Health of Aircraft Cabin Environments—Stage 2 A consultation on the possible January 2001 Published: 4 Sept 2001 safety briefing, backed up by a standardised card R esearch D ocuments and R eports Date2000 Title Author Commissioning Authority Location in seat-back pockets (Paragraph 9.8). 1.47 We recommend airlines tosystems review and their procedures for dealingpassenger with concerns and complaints sopassengers that do not feel thatto they deal are with being lawyers forced andoutset. insurers This from review the should includeindependent the ‘ombudsman’. case (Paragraph for 8.60) an 3844421015 Page Type [O] 30-11-07 13:08:21 Pag Table: LOENEW PPSysB Unit: PAG3

air travel and health: evidence 95 http://www.dft. gov.uk/pgr/ aviation/hci/hacc/bre/finalreport http://www.caa. co.uk/docs/33/ CAPAP2004 04.pdf http://www. advisorybodies .doh.gov.uk/pdfs/annex10tox0621 ice.pdf http://www.dft .gov.uk/pgr/ aviation/hci/hacc/ppdvt/ Project details: The National Research Register http://www.nrr .nhs.uk/ ViewDocument.asp? ID % N0123124617 http://www.dft.gov.uk/pgr/ inclusion/dvt/asprin/ http://www.opsi.gov.uk/ACTS/acts2006/ 20060034.htm Explanatory notes: http://www.opsi.gov.uk/ACTS/en2006/ 2006en34.htm http://eur-lex.europa.eu/LexUriServ/site/en/ oj/2002/l 240/l 24020020907en00010021.pdf http://europa.eu.int/eur-lex/pri/en/oj/dat/ 2000/l 302/l 30220001201en00570060.pdf http://www.opsi.gov.uk/si/si2004/ 20040756.htm http://ec.europa.eu/transport/air/rules/rights/ doc/commitment airlines en.pdf – – – – Department of Health Civil Aviation Authority DFT& BATA DfT and European Commission DH Dr W Maton-Howarth Secretary of State’s duty ofcarrying organising, out and encouraging measuressafeguarding for the health of personsaircraft. on Corresponding board duty on CAA. Common rules in the fieldand of establishing civil a aviation European AviationAgency Safety Concerning the European Agreement onOrganisation the of Working Time ofWorkers Mobile in Civil Aviation Legislation transposing the above The European Commission has encouraged airlines and airports to preparecommitments voluntary to improve their qualityservice. of Most airports and airlinessigned have up, as recommended byrepresentative their associations. Functions with respect to health. The David Ross, Derrick Crump, Colin Hunter, Earle Perera and Agnes Sheridan CAA paper 2004/04 HR Bller, Academic Medical BRE (co-ordinator) Research Works Ltd FR Rosendaal, Leiden University Medical Centre Centre, Amsterdam DfT Summary: http://www.dft.gov.uk/stellent/ groups/dft mobility/documents/ page/dft—mobility—610897.hcsp Synovate Healthcare BRE: – Regulation (EC) No 1592/2002 OfEuropean The Parliament And Of The Council Council Directive 2000/79/EC (Statutory Instrument 2004 No.756) The Civil Aviation (Working Time) Regulations 2004 Airline Passenger Service Commitment on Air Passenger Service Civil Aviation Act 2006 measurements to include older aircraft types utilised in high volume short haul operation Cabin Air Quality Protocol (Started Oct 2005) Thrombosis (DVT) thrombosis Flights. ICE—Ideal Cabin Environment Public Perceptions of Deep Vein WRIGHT project—WRIGHT I Air travel and deep vein Summary published on DFT website The Extent of Aspirin UseProphylaxis for of the DVT on Long Haul Extending Cabin Air February 2004 June 2006 15 Oct 2003 April 2005October 2005 21 Dec 05 21 Dec 2005 Published: WRIGHT II—Phase 2 Protocol28 April 2006 FR Rosendaal & HR Bller 15 July 2002 27 November 2000 13 April 2004 presented to the public in May 2001 October 2003 L egislation Date11 October 2005 Title Subject Location 3844421015 Page Type [E] 30-11-07 13:08:21 Pag Table: LOENEW PPSysB Unit: PAG3

96 air travel and health: evidence http://www.opsi.gov.uk/SI/si2005/ 20051970.htm http://europa.eu.int/eur-lex/pri/en/oj/dat/ 2003/l 042/l—04220030215en00380044.pdf http://www.opsi.gov.uk/si/si2005/ 20051643.htm – Smoking in aircraft The minimum health and safetyregarding requirements the exposure of workersrisks to the arising from physical agents (noise) Legislation implementing the above PART 5: Operation of Aircraft Item 76: (Statutory Instrument 2005 No. 1970) European Directive 2003/10/EC Physical Agents (Noise) Directive The Control of Noise at2005 Work (Statutory Regulations Instrument 2005 No. 1643) The Air Navigation Order 2005 February 2006 6th April 2006 20th August 2005 18 July 2007 3844421015 Page Type [O] 30-11-07 13:08:21 Pag Table: LOENEW PPSysB Unit: PAG3

air travel and health: evidence 97

Letter from the Department for Transport I am writing to bring urgently to your attention an error in the evidence given to the Committee on 17 July by myself and the chair of the Aviation Health Working Group, Mrs Sandra Webber. On looking back we find that we over stated the incidence of aircraft “fume events”. The error occurred in response to Question 11. In my statement to the Committee I said that fume events occurred in around 0.5% of cases (half of 1%). This figure was repeated in questioning by members of your Committee and by my oYcials. This figure should have been 0.05%—ie one in every 2,000 cases rather than one in every 200 cases. The draft of the final report of the independent Committee on Toxicity, which is posted on its website under reference number TOX/2007/20 Annex 7, says in paragraph 26: “It has been estimated from information provided by three airlines to the COT that overall engineering confirmed smoke/fume incidents occur in around 0.05% of flights (sectors) but that the incidence may be higher than this in some circumstances, depending on airframe, engine type and servicing.” I hope that this information is helpful, and I apologise to you and the Committee for inadvertently exaggerating the prevalence of fume events. 12 September 2007 3844421016 Page Type [SE] 30-11-07 13:08:37 Pag Table: LOENEW PPSysB Unit: PAG4

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Written Evidence

Memorandum by the the Aerospace Medical Association

PositionStatement onAircraftCabinPressure In the first decades of the 20th Century, when aviation was in its early days, aeronautical engineers and aviation medicine practitioners explored the question of what would constitute an acceptable cabin altitude. Although there are no precise records of their deliberations, the literature does indicate that the agreed maximum cabin altitude of 8,000 feet was a compromise taking into consideration aircraft design, operational requirements, and human performance. Practically every regulatory agency and airline in the world has accepted this compromise. In recent decades, some experts have advocated lowering the maximum cabin altitude from 8,000 feet to 6,000 feet presuming this would enhance cockpit and cabin crew performance and protect the health of the passengers. But is there evidence of this? Recommendations to lower cabin altitude are based upon the reasonable assumption that a higher ambient pressure and the resulting improved pO would lessen the risk of exacerbation of pre-existing illness (particularly cardiopulmonary) and barotrauma.2 Although there have been a number of articles published in the literature describing inflight medical events, including death, we have been unable to find a correlation of these events with cabin altitudes below about 10,000 feet. On the other hand, we know that some passengers develop a broad array of nonspecific symptoms during flight including anorexia, nausea, fatigue, headache, and insomnia. We do not know the cause of these symptoms although, for the most part, they are relatively minor and resolve quite rapidly postflight. Anecdotal evidence seems to suggest that some cabin crew (flight attendants) may similarly experience such transient symptoms which may be aggravated by the nature of their work, which can be quite physically demanding at times. While it would be physiologically plausible for this to happen, there are however, no studies documenting the relationship especially with regard to an “acceptable” cabin altitude where these eVects are significantly minimised. It is a known fact that exercise can aggravate symptoms of hypoxia especially in cardiorespiratory compromised individuals. This would happen at any altitude above sea level and would be increasingly severe, the higher the altitude. Again, the question of an “acceptable” altitude remains unanswered. From an occupational health standpoint, workers who are not reasonably fit for the environmental conditions expected within an aircraft cabin, may need to be redeployed. 1,2 Regarding performance of cockpit crew, McFarland and Barach did a number of seminal studies some years ago to determine if there is a3 decrement in cockpit performance with increasing cabin altitude. It was observed that there is, in some cases, a small but not a significant decrement in vision and psychomotor skills until one reaches a cabin altitude above 10,000 feet, well beyond the prescribed 8,000 feet cabin altitude. Likewise, Denison et al (1961) reported small decrements in response time during orientation tasks at 8,000 feet relative to 5,000 feet and at both altitudes relative to sea level performance. It is reasonable to assume that there is no added threat to civil flying safety due to performance decrement with an 8,000 feet cabin altitude. In summary, we could find no evidence that lowering the cabin altitude would prevent significant adverse health eVects on reasonably healthy passengers and cabin crew nor significantly enhance performance by cockpit crew. One can only presume that a lower cabin altitude might be more conducive to preventing illness in flight, but this is only conjectural. Therefore, the Aerospace Medical Association cannot, at this point, recommend a lowered cabin altitude based solely upon health and cockpit performance considerations. The Aerospace Medical Association would encourage more research to be done into this area. 30 May 2007

1 2 197-207. 3 McFarland R Human Factors in Air Transportation. New York, McGraw-Hill Book Co Inc. 1953. BarachMed 1996; AL, 10: McFarland 1010–1013 RA, Seitz CP. The eVects of oxygen deprivation on complex mental functions. J Av Med—1937; 8 ( 4): Denison DM, Ledwith F, Poulton EC. Complex reaction times at simulated cabin altitudes of 5,000 feet and 8,000 feet. Aerospace 3844421016 Page Type [O] 30-11-07 13:08:37 Pag Table: LOENEW PPSysB Unit: PAG4

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Letter from the Aerotoxic Association I watched the Committee’s inquiry with interest, but regret to inform you that much factual evidence was not presented to your inquiry. It is always hard to know which pieces of evidence might convince you that there is a massive problem looming in the aviation industry; but as with the Hatfield rail accident several years ago, perhaps the true state will only become understood in the aftermath of an actual fatal accident when inconvenient evidence finally emerges. Here are some examples to illustrate the sort of cracks that are being currently papered over: — A pilot fell asleep in a simulator due to fatigue caused by contaminated air and lost his job; — I elected not to fly a Public Transport aircraft on three separate occasions citing fatigue in 2004–05; — In February 2007 a passenger flew to the US, she and her whole family were made ill; when a complaint was made to the airline they claim she was the only one to complain. It then transpired that 40 other people have complained of the same problem; — I applied for a personal Flight Safety report from the CAA to be released—nearly a year ago. The Freedom of Information act has still failed to allow that report to be seen by me; — A cabin attendant who flew a diVerent aeroplane with a diVerent airline but lives 25 metres from me and who lost her job due to a “mysterious undiagnosed illness” admits to identical medical symptoms. Her health issues have never been understood by doctors for over six years; — Numerous pilots reporting ill health, which is conveniently labelled as “psychosomatic” by doctors who are now known to be “amazingly ignorant” (Professor Bagshaw) and mistreated with anti- depressants. Further factual information you may be aware of, and I regret that the Committee was not able to question the specialists about: — In December 2005 I went to see Professor Muir with many other pilots from my low cost airline with evidence of illegal rostering, as she was commissioned by my airline into “the reasons why so many pilots are leaving”; — Professor Bagshaw grounded me, after a 30 year career in aviation (the last 16 years of which was flying the BAe 146) in February 2006 with “chronic stress”. In March/April 2006 I was tested by Dr Sarah Mackenzie Ross of UCL and was found to have been chronically poisoned along with 26 other pilots. Why was this not untypical occurrence reported to the Committee? — In February/March 2007, the Air Transport Users Council were given full details of the injury sustained by a family and others travelling to the US, but rejected any liability for health issues. This again was not mentioned at the inquiry; — BALPA have stopped answering letters from several members, who have suVered ill health from contaminated air, despite acknowledging a serious problem does exist and that many member pilots are ill. There are many, many more incidents. How is it that they fail to see the light of day until after an accident? I would be grateful if you could either contact the above for further details or I would be willing to supply you with the evidence directly, as I am sure you will agree that the present cover up is totally unacceptable in a democratic society which fortunately still enjoys freedom of speech. 16 July 2007

Memorandum by Airbus Airbus welcomes this opportunity to give its views in this written submission to the House of Lords Science and Technology Committee follow-up inquiry into “Air Travel and Health”.

CompanyBackground andIntroduction Airbus SAS is a wholly owned subsidiary of EADS NV, a global aerospace and defence company. Airbus SAS has design and manufacturing facilities in France, Germany, the UK and Spain as well as subsidiaries in the US, China and Japan. The UK business is the Airbus wing leader and is responsible for the design, development, production and integration of wings for all Airbus aircraft produced to date. It is the global head quarters for Airbus’ Wing and Pylon Centre of Excellence. The UK is also responsible for fuel system and landing gear integration. 3844421017 Page Type [E] 30-11-07 13:08:37 Pag Table: LOENEW PPSysB Unit: PAG4

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The subject matter being covered in this inquiry is in the domain of the global Centre of Excellence for Aerostructures led by Airbus in Germany, which has responsibility for design and development of the fuselage. Since the original inquiry, two major EC-funded projects on cabin environment and occupant health, comfort and well-being have been undertaken. “CabinAir” (which ran from January 2001 to December 2003) and ICE (Ideal Cabin Environment), which is now mid-way through, having completed a test campaign on 1500 passengers. Airbus is a contributor to both projects and more information is provided in section 2. In addition there have been activities sponsored by ASHRAE (American Society of Heating Refrigeration and Air Conditioning Engineers) in the USA, to which Airbus has also provided technical support as required by the investigation consortia. A number of internal Airbus projects remain commercially confidential; however one, which looks at trigger points for real time air monitoring, will be discussed in this submission.

InquiryQuestions

What progress has been made in research into the priority areas identified by the Committee in 2000? The 2000 Committee inquiry was presented with some of the results from Airbus’ measurement campaign in this area. More details are provided in an article published in Airbus’ customer magazine. In addition, Airbus has participated in the European project known as “CabinAir” where extensive in-flight measurements were carried out. No abnormal contaminants or contaminant concentrations were identified during this measurement campaign, and thermal comfort in Airbus aircraft was found to be within the comfort range. In-flight monitoring is also a major part of the ASHRAE research project 1262 (“Relate air quality and other factors to comfort and health related symptoms reported by passengers and crew on commercial transport aircraft”), for which Airbus is providing technical support as needed. Again, the pilot project did not identify any anomalies with the cabin environment. Research to aid understanding of the interdependent eVects of the cabin environment parameters has been a priority for Airbus for several years. As part of this eVort Airbus is a partner in the European project “Ideal Cabin Environment” (ICE). One of the major goals of ICE is to address the aspect of combined eVects of the aircraft environment on the occupants and measurements have been carried out in two test facilities, the pressurised flight test facility (FTF) at the Fraunhofer Institute for Building Physics near Munich and the unpressurised Building Research Establishment ACE (Aircraft Cabin Environment) in the UK. Airbus has provided technical expertise regarding normal aircraft operations to support the test programme primarily in the areas of: — temperature control; — ventilation; — pressurisation; — humidity control; and — noise. More detailed explanation of the ICE work plan is available, however Airbus understands that submissions made by other contributors to the inquiry will address the ICE project in more detail.

Do gaps remain in the evidence base and, if so, are they being filled? In order to support eVorts to improve real-time monitoring, specifically in the case of smoke or fume events, Airbus has launched an internal project 6048 to investigate trigger compounds, concentrations and appropriate sensors that could be used to indicate ingestion or failure at the APU (Auxiliary Power Unit) and/ or engines. The project is primarily focused on: — compounds present during smoke or fume events; — concentration of associated compounds; and — appropriate sensor technology. This study is on-going, and it is anticipated that significant validation eVorts will be required, since the occurrence of these types of events is so infrequent that an accurate model of cabin eVects has not yet been fully developed. 3844421017 Page Type [O] 30-11-07 13:08:37 Pag Table: LOENEW PPSysB Unit: PAG4

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Have any new health concerns emerged since 2000, and what is being done to address them? We do not believe that there are new health concerns that have emerged since 2000, however it is clear that SARS and avian flu have focused attention on aspects of disease transmission within the cabin. Airbus has been supporting airlines concerned by providing operational and maintenance advice on how to best react to this situation (via Operator Information Telex, a non-urgent product and engineering information bulletin). To be prepared for the case of mutation of the H5N1 virus with sustained human-to-human transmission, an initial working group consisting of Airbus, Boeing and the WHO was convened by Airbus shortly after the SARS epidemic. This working group has now been re-established by IATA and ICAO with participation of the WHO, CDC, ICAO, IATA, Airbus and Boeing. Another concern that is not new but that has gained increasing public awareness is that of bleed air contamination events. Airbus has been monitoring reports of failures leading to cabin air contamination, and where necessary has introduced modifications to resolve specific failure cases. However, there is no evidence of systematic bleed air contamination due to design failures on Airbus aircraft. Information regarding environmental control system contamination sources has been made available to airlines through Service Information Letter 21-123. In support of these activities Airbus internal research project 6048 has been designed to determine a means for identifying a trigger point for a smoke or smell event. To date the main area of uncertainty regarding this topic is the lack of data during a failure event. Airbus is aware of the research in this area recommended by the Committee on Toxicity (COT) and the ACER project being sponsored by the FAA in America and hopes that this research will provide large enough test populations to be able to capture data from these very infrequent events.

Has new evidence invalidated any of the recommendations made by the Committee in 2000? In Airbus’s view no additional evidence has invalidated the Committee’s recommendations from 2000 with respect to the recommendations specifically directed toward aircraft manufacturers. It is important to point out that some of the recommendations, specifically concerning HEPA filtration and Ozone Converters, are already applied on current Airbus production aircraft. For those aircraft not in current production retrofit solutions exist for airlines to bring their aircraft up to the current industry standard. Airbus was part of the European project CabinAir consortium and supported the development of standard prEN4618. This standard provides performance based limits to ensure air quality within aircraft cabins, and was jointly developed with wide general interest, industry and regulatory participants. Airbus is playing an active part in the European project ICE (see above) and providing technical support (where required) to assure successful completion of the ASHRAE research project No: 1262. One of the ICE project deliverables is a new European pre-standard for the aircraft occupant well-being and comfort and the cabin environment.

How effective has the inter-departmental Aviation Health Working Group been in taking forward the Committee’s recommendations? How are the arrangements for governance and regulation of the industry working? The CAA’s Aviation Health Unit (AHU) participation in ICE has bought useful health oversight to the project. The continued contribution of a facts and science-led team within this domain is to be welcomed. The regulatory framework continues to evolve with harmonisation activities between the JAA and FAA regulations and the establishment, and increasing responsibilities, of EASA. If significant, new, health relevant facts are discovered they should be considered by the whole industry, including the airworthiness authorities, within the existing regulatory framework in order to decide whether changes are needed to the regulations.

How successful have the Government been in raising international awareness of passenger and crew health, and in improving international collaboration? Naturally Airbus seeks as much as possible to work collaboratively on the subject of the cabin environment and occupant health where this does not overlap with competitive imperatives. One area Airbus would like to see continued governmental engagement in is support of the COT investigation and wide dissemination of results. 3844421017 Page Type [E] 30-11-07 13:08:37 Pag Table: LOENEW PPSysB Unit: PAG4

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What progress has the airline industry itself made since 2000? One of the recommendations outlined by the Committee concerns in-service performance monitoring of filters. Monitoring systems are already in place on the A330 and A340 family of aircraft, and this system has been further integrated within the A380 environmental control system. Before each flight the pressure drop of the filtration system is verified, and if the measured pressure is out of limits (within a given margin of error) a warning message (Class 5) is generated. The airline can use this maintenance warning to plan the filter replacement. Combined HEPA and active carbon filters have been oVered by Airbus as an option for airlines to improve the cabin environment. These combined filters act to remove not just particulate but also gaseous contaminants from the re-circulated air. Methods for controlling the cabin air inflow have been developed and introduced with the A340-500 and A340–600 aircraft (entry into service 2002–03), and are also used on the A380. The flow management system introduces several benefits for the occupants and airlines. The amount of air delivered to the cabin is controlled based on the number of occupants on board. This has two major benefits for the occupants; better thermal control and higher humidity levels. Additionally, the airlines gain an energy eYcient benefit by having reduced fuel burn on those flights with lower load factors. Active humidification systems have been developed for specific areas or zones within the cabin and crew rest facilities. These systems have been designed to provide increases in the relative humidity over and above what flow management systems may achieve, but to targeted areas. For instance, specific cabin zones, such as crew rest compartments, can be humidified to increase comfort to the occupants in those areas. The application of active humidification systems is however limited by the amount of water needed to operate the system. The amount of water depends on the eYciency of the system itself, the volume to be humidified and the length of time the system is operational. Ozone converters are oVered as standard fit for all long-range aircraft to meet airworthiness requirements. A further development of this technology has allowed Airbus to oVer combined ozone and odour reduction converters as an option for airlines. The exhaust fumes from ground service vehicles and other aircraft can be ingested during the ground phase. These fumes do not have health implications, being part of the surrounding airport environment, however can lead to discomfort (odours) for the aircraft occupants. These combined filters remove ozone to meet the airworthiness directives as well as removing gaseous odours entering the cabin via the bleed system during ground operations. The capabilities for medical treatment on board in case of an in-flight medical emergency have been improved in several aspects. Many aircraft nowadays have automated external defibrillators on board to treat specific types of cardiac arrest. The use of telemedicine devices to exchange information with a medical ground centre has become quite common and related technologies are improving. Airbus engineering provides support to airlines for the installation of both of these facilities. Successful application of telemedicine has been demonstrated on A340-600 together with Lufthansa and Virgin Atlantic Airline crews during the pre- commercial entry to service evaluation flights. As ultra long haul flights become more frequent health and comfort aspects of the aircraft cabin and the environmental control systems have been further developed. Due to the increased probability for the occurrence of an inflight emergency with a greater number of passengers on board and longer flight times, novel solutions, such as first aid modules, have been developed for the A340-500/-600 and the A380. Additional possibilities for improvement of medical treatment on board of long haul aircraft have been also analysed by Airbus and will be further investigated in consultation with medical experts. Although development of the A350 XWB is in its early phases, Airbus fully intends to apply the results from theƒ6 million ICE project, as well as results from the German Government funded “LUFO” projects, a series of cabin related environmental control research projects.

To what extent has the information supplied to travellers been improved and integrated since 2000? Airbus believes that this question falls under the responsibility of the airlines. One of the goals of ICE however is to ensure wide dissemination of the study results, including to passengers. Airbus’s participation in the ICE project means that additional support for the partners responsible for these deliverables will be provided if requested. 19 June 2007 3844421018 Page Type [O] 30-11-07 13:08:37 Pag Table: LOENEW PPSysB Unit: PAG4

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Memorandum by Association of Flight Attendants On behalf of our 55,000 members of the Association of Flight Attendants-CWA, AFL-CIO (AFA), employed at 20 airlines here in the United States, the Association is responding to the call for evidence for the “Air Travel and Health” follow up inquiry. Specifically, we wish to provide information that has emerged since your 2000 inquiry on the following two health concerns for occupants on commercial aircraft: (1) Exposure to insecticides applied in the cabin and flight deck, largely to comply with foreign quarantine regulations of 47 countries; and (2) Exposure to pyrolyzed engine oil and hydraulic fluid that sometimes contaminate the aircraft air supply.

Exposure toInsecticides 1. Paragraph 4.28 of the 2000 Report notes that “some health authorities have queried the wisdom of aircraft disinsection”, but still concludes that “insect control procedures are not a significant health issue” based on the apparent paucity of specific reports. The shortage of independently verified data must be noted in the context of the following facts: (i) Neither passengers nor crewmembers are informed of residual spraying requirements so they do not know what they have been exposed to; (ii) Passengers and crew are only informed of in-flight spraying requirements during the flight and are formally assured that the sprays are safe; (iii) Airlines need not provide either passengers or crew information on the contents of either the residual or inflight sprays; (iv) Passengers and crew can and do report symptoms to the airlines and to their physicians, but airlines need not publicise or share these reports and physicians need not report them to a centralised database to facilitate public health alerts; and (v) There is no centralised reporting system that monitors this or any other crew or passenger health concern. For these five reasons, it seems premature—and even irresponsible—to dismiss the health concerns associated with disinsection practices without conducting a formal and independent investigation into the prevalence of reported symptoms on such flights. 2. In 2000–01, the California Department of Health Services investigated reports of acute illness reported to physicians by cabin crew and attributed to insecticide exposure on aircraft. Recently, a peer-reviewed paper was published on the results of that investigation (Sutton, 2007). Chronic health eVects attributed to exposure to pyrethroid insecticides on aircraft have been reported widely to crewmembers’ physicians and to our union, but funding to conduct a controlled, detailed investigation has not been available. 3. In early 2002, the United States (US) Department of Transportation (DOT) initiated an inter-agency task group with input from six other US Government agencies. Its goal is to develop and assess the eYcacy and feasibility of a method of disinsection that could be achieved through mechanical means instead of chemical spraying. Since then, members of the inter-agency task group have tested the eYcacy of simple air curtain technology to keep insects oV aircraft (or on aircraft, depending on the direction of the airflow and according to the arrival or departure point in question), intended to protect a passenger boarding door equipped with a boarding bridge. This work has since been published in the peer-reviewed literature (Carlson, 2006). The group is now finalising testing on a custom net curtain solution intended to prevent insect entry through the aircraft service doors and through passenger boarding doors equipped with stairs. The group is also in talks with several interested countries. 4. Finally, since your 2000 inquiry, the International Civil Aviation Organization updated its Standard 2.24 to allow countries to adopt WHO-approved non-chemical methods of disinsection as an alternative to the typical chemical methods (ICAO, 2004). I encourage you to investigate these options further as part of your follow- up inquiry.

Pyrolyzed engine oils in the aircraft air supply (“contaminated bleed air”) 5. There is little dispute that engine oil and hydraulic fluid can and does contaminate commercial aircraft air supply systems (Bobb, 2003; NRC, 2002; SAE, 1997), and that when this happens, flight safety can be compromised (AAIB, 2007; AAIB, 2004; CAA, 2001; CAA, 2000). However, despite the volume of documented crewmember symptoms that span decades of flying (Michaelis, 2003; Witkowski, 1999; Rayman, 1983; Montgomery, 1977), there is still a diversity of opinion on the severity of health impact because there are no air quality monitoring data collected during an event, no standardized medical test to definitively prove 3844421018 Page Type [E] 30-11-07 13:08:37 Pag Table: LOENEW PPSysB Unit: PAG4

104 air travel and health: evidence exposure, and no diagnostic tests to definitively prove the relationship between exposure and reported symptoms. 6. The frequency of air supply contamination events is also under dispute because of underreporting and the absence of a comprehensive source of reports. In March 2007, James Burin, Director of Technical Programs for the Flight Safety Foundation, estimated that five to ten aircraft per day are diverted around the world due to smoke-fire-fumes events, most of them smoke. This estimate was based on accident/incident research and discussions during international meetings with airlines and manufacturers, but he did not know how many of these were caused by oil or hydraulic fluid. Other sources of smoke/fumes include in-flight fires and electrical faults. Of course, any source of smoke or fumes in the flightdeck/cabin creates a potential health and safety hazard, but AFA has been especially concerned about such fumes that contain engine oils or hydraulic fluids because they contain some very toxic ingredients. 7. In 2002, the US National Research Council published the following frequency estimates for air supply contamination with engine oil or hydraulic fluid for a small selection of aircraft types, all presented as number of events per 1,000 flight cycles: 3.88 for the BAe146; 1.29 for the A320; 1.25 for the B747; 1.04 for the DC- 10, 1.02 for the MD80, 0.63 for the B767, and 0.09 for the B737 (NRC, 2002). These estimates were based on several years of data from three airlines. To put these numbers in context, there were an estimated 10,556,000 departures on US airlines last year (BTS, 2007), so even the most conservative estimate of 0.09 events per 1,000 flight cycles fleet-wide, for example, translates into 950 events per year in the US fleet or an average of two to three events every day. 8. I am in the midst of compiling smoke/fumes incident data from the following four sources: (i) Copies of reports that our members submitted to their airlines, assuming that they also reported the events to AFA; (ii) News media reports, typically of diversions or major delays due to smoke or fumes (not always specific as to source of smoke); (iii) Reports that US airlines submitted to the Federal Aviation Administration (FAA) Service DiYculty Reporting system (per 14 CFR 703); and (iv) Reports that US airlines submitted to the Aviation Incident Database System. The dataset is restricted to those events that involved a smoke, fume, mist, haze, or odor likely or definitely caused by pyrolyzed engine oil or hydraulic fluid. Events for which another cause (such as an electrical fault or de-icing fluid) could be identified are excluded. Data collection and analysis is ongoing but from these four incomplete and largely underused sources of information, I have documentation on 293 events for a 16.5 month period (1 January 2006–11 May 2007), translating into an average of 0.59 events per day on the US fleet alone that likely or definitely involved engine oil or hydraulic fluid in the cabin/flight deck. These four data sources are a starting point, but aside from the fact that the data collection is ongoing, they are guaranteed to underestimate reality for the following reasons: (i) Our union, AFA, only represents about half of the flight attendants in the US, so we only have the potential to review about half of the contamination events reported by flight attendants, assuming that these events are neither more nor less common at AFA airlines. Further, there is no guarantee that AFA members will send a copy of their airline report to the union, or if they do, that our particular department will get a record from either the member or the local union oYce. So, at best, we had access to a fraction of the events documented by US flight attendants with their airlines. (ii) Airlines under-report to the FAA. Specifically, the FAA requires airlines to report “each failure, malfunction, or defect concerning an aircraft component that causes accumulation or circulation of smoke, vapor, or toxic or noxious fumes in the crew compartment or passenger cabin during flight” to its Service DiYculty Reporting (SDR) system per Federal Aviation Regulation (FAR) 703(a)(5). Airlines must also report ground-based events that involve a failure, malfunction, or defect that has endangered or may endanger the safe operation of the aircraft per FAR 703(c). However, in May 2006, the FAA distributed a bulletin to its inspectors stating that “it appears as though there are numerous air carriers/operators who may not have reported these [smoke/fumes in the flight deck/ cabin] events as required by regulation” (FAA, 2006). Put simply, even the FAA recognises that airline compliance with its reporting rules is poor. As an example, of the4 105 events recently documented by our members with their airlines, I was only able to identify four in the FAA databases. Similarly, of the 39 smoke/fume events identified in the media (typically serious enough to require a diversion), I was only able to identify three in the FAA databases.

4 airlines reported a greater number of events to the FAA than these numbers suggest, but dramatic under-reporting is still evident. The compilation of reports submitted to the FAA during this period is about 90% complete so we may ultimately conclude that the 3844421018 Page Type [O] 30-11-07 13:08:37 Pag Table: LOENEW PPSysB Unit: PAG4

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(iii) Airlines need not monitor the air so for an event to be reported, there must be suYcient contamination for crewmembers to either smell or see the problem, and they must fill in the paperwork knowing that there is a high probability that the incident will get ignored and any associated workers’ compensation claim will be denied. Under-reporting (both intentional and unintentional) by crew is a real problem and it is hard to overcome the obstacles of no inflight warning systems, low morale, and low expectations of an appropriate response from the airlines. 9. Of the events with complete phase of flight information, a little more than half diverted. Many of those that did not divert were either in descent or taxi-in, so instead conducted emergency landings. We do not have enough information to know if the subsequent flights were cancelled, but presumably they would have at least been delayed so that maintenance staV would have time to troubleshoot. 10. The fact that about half of these events required a diversion and likely all caused potentially expensive and unpopular delays is important because it presents a business case for preventing these events with improved maintenance practices and air cleaning equipment, and it justifies the investment in sensor equipment designed to identify an event in its early stages. In 2006, the FAA estimated the average cost of a diversion at $207,000, obviously varying by size of aircraft and requisite ground time to troubleshoot and fix any mechanical failure. So, some or all of the cost of air cleaning equipment for the outside air will clearly reduce diversion costs associated with smoke and fumes. Similarly, some or all of the expense of chemical sensor equipment that allows an airline to identify and address minor problems before they become serious and costly may be oVset by saved diversion costs. For example, one major US airline submitted a report to the FAA last year of an extremely foul odour from the air packs after liftoV. It described the forward and aft cabin air quality as poor but noted that maintenance found no evidence of an oil leak. On that same aircraft eight days later, strong fumes entered the flight deck at takeoV and remained through the climb. Maintenance finally identified three oil leaks and replaced the engine. That later event could have been prevented had there been some objective indication of oil leaking in the cabin on the earlier flight or if the aircraft had been equipped with air cleaning equipment. 11. In closing, we know that, by definition, the outside air supplied to the cabin and flight deck is first processed in the engines or APU where it can be contaminated with pyrolyzed engine oil or hydraulic fluid. The only exception to this rule is the B787 that will enter service in 2008 and rely on a non-bleed air system, both on the ground and inflight. To this end, the frequency and potential severity of air supply contamination events present an obligation for government bodies to investigate and promote preventive and remedial measures. Options include installing commercially viable air cleaning devices on the outside air supply, prompt and eVective cleaning of contaminated systems, and an obligation to inform crew and passengers of onboard exposures. On behalf of our members, we thank you for your interest in these exposures onboard commercial flights. 18 June 2007

References AAIB (2007) Bulletin no 4/2/07, Bombardier DHC -8-400, G-JECE (EW/C2005/08/10), UK Air Accidents Investigation Board. AAIB (2004) Report no 1/2004, BAe146, G-JEAK (EW/C2000/11/4) UK Air Accidents Investigation Board. Bobb, AJ (2003) Known harmful eVects of constituents of jet oil smoke TOXDET-03-04 Naval Health Research Center Detachment (Toxicology), Wright-Patterson AFB, OH. BTS (2007) Airline Activity: National Summary (US Flights). Bureau of Transportation Statistics, US Department of Transportation, Washington, DC. See www.transtats.bts.gov CAA (2001) Flight Operations Department Communication (FODCOM) 14/2001 UK Civil Aviation Authority, Safety Regulation Group, Aviation House, Gatwick, West Sussex, England. CAA (2000) Flight Operations Department Communication (FODCOM) 17/2000 UK Civil Aviation Authority, Safety Regulation Group, Aviation House, Gatwick, West Sussex, England. Carlson, D A; Hogsette, J A; Kline, DL; et al (2006) “Prevention of mosquitoes and house flies from entering simulated aircraft with commercial air curtain units” J Econ Entomol, 99(1): 182–193. FAA (2006) Flight Standards Information Bulletin for Air Worthiness (FSAW) 06-05A “Guidance for smoke/ fumes in the cockpit/cabin” US Federal Aviation Administration, Washington, DC. ICAO (2004) Meeting of the Facilitation (FAL) Division of the International Civil Aviation Organization, Working Paper 117 (FAL/12—WP/117), Cairo, Egypt. Michaelis, S (2003) “A survey of health symptoms in BALPA B757 pilots” J Occup Health Safety–Aust NZ, 19(3): 253–61. 3844421018 Page Type [E] 30-11-07 13:08:37 Pag Table: LOENEW PPSysB Unit: PAG4

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Montgomery, MR; Wier, GT; Zieve, FJ; et al (1977) “Human intoxication following inhalation exposure to synthetic jet lubricating oil” Clinical Toxicol, 11(4): 423–26. NRC (2002) The airliner cabin environment and the health of passengers and crew US National Research Council, ISBN 0-309-08289-7, National Academy Press, Washington, DC. SAE (1997) Aerospace Information Report 1539 Rev A. Society of Automotive Engineers International, Warrendale, PA. Sutton PM, Vergara X, Beckman J, Nicas M, Das R. (2007) “Pesticide illness among flight attendants due to aircraft disinsection” Am J Ind Med, 50: 345–356. Witkowski CJ (1999) “Remarks on airliner air quality” Presentation at semi-annual conference of the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE), Chicago, IL.

Memorandum by the Aviation Organophosphate Information Site (AOPIS) AOPIS is a non-profit group set up originally in Australia in 2001. AOPIS now has pilot and cabin crew members in 14 countries globally and over 1,000 on our database with a large UK membership. Our members include those who have either suVered short or long term medical eVects from exposure to contaminated air on commercial aircraft or crew who care about the issue. AOPIS is the leading non profit representative voice on the issue of contaminated air and was one of the main sponsors of the two day International Aero Conference that took place in London In April 2005. The International Aero Conference was called for by the then MP Paul Tyler now Lord Tyler, and John Smith MP and organised in the UK by the British Airline Pilots Association (BALPA). 5 Our submission will focus specifically on contaminated air and on the fact that the UK CAA have not only failed to act to protect the travelling public and working crews, but have actively in our opinion, misinformed on the issue to protect the aviation industry that exclusively funds them. AOPIS will clearly show that in connection with protecting the travelling public and crew health, as well as their safety, during what is known as a “contaminated air event”, the UK CAA have negligently failed to meet their duty of care towards the traveling public as well as the pilots and cabin crew who spend their working lives on commercial aircraft. These may seem harsh words to use in connection with what is generally accepted to be one of the worlds finest safety regulators, but our focus and concerns are solely in one arena, an arena which is the AOPIS raison d’eˆtre: contaminated air. The failure of the CAA in this regard is not just related to UK aviation but has serious international consequences. The CAA is looked upon as a leading aviation regulator and is in a unique position of being able to shield the British Aviation Industry. Their failure has a domino eVect throughout the industry globally. Our comments are referenced and factual and need action from the Transport Committee to influence much needed change. To understand these CAA failings, one needs to understand what a contaminated air event actually is. An event occurs when the air supply provided to the passenger cabin and cockpit becomes contaminated with engine oils or hydraulic fluids. This air supply known in the industry as “bleed air” is normally supplied by either the engines or the small engine usually located in the tail of an aircraft, known as an Auxiliary Power Unit (APU). The air supply should be 100% clean air but when it becomes contaminated this is known as a contaminated air event. The evidence against the CAA is extensive. The CAA has known about the problem of contaminated air events and its eVects for over 20 years but has simply selected some cases of complete impairment and not cared much about partial impairment or any aspect related to passenger and crew health. Information that has been known for 25 years is extensive and includes: 1977: A 34 year old military navigator in a Lockheed C-130 Hercules military transport aircraft experienced acute intoxication following inhalation of vaporized6 or aerosol synthetic lubricating oil from contaminated bleed air. Symptoms included headache, nausea, dizziness, vomiting, inco-ordination, lethargy, diYculty standing etc. The report concludes “Further investigation7 into the potential hazards from inhalation of synthetic oil fumes . . . is definitely warranted”. 1981: Society of Automotive Engineers (Aerospace), “Engine compressor bearings upstream of the bleed ports are the most likely sources of lube oil entry in the engine air system and thence into the bleed system contaminating the cabin/cockpit air conditioning systems . . . At temperatures above 320)C this oil breaks down into irritating and toxic compounds”.

5 Email from A Wallace, CAA Corporate AVairs—August, 2003. 6 CAA—“Thelubricating oil. UK Clin CAA Toxicol is fairly 11:423–426. unique in that it is funded entirely by the industry that it regulates and receives no government finance.” 7 Montgomerycontamination. MR, Society Wier of GT, Automotive Zieve FJ, Engineers, Anders MW Warrendale, (1977) Human PA. intoxication following inhalation exposure to synthetic jet SAE (1981) Aerospace information report AIR 1539, 30/1/81, environmental control system contamination: sources of vaporous 3844421019 Page Type [O] 30-11-07 13:08:37 Pag Table: LOENEW PPSysB Unit: PAG4

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1983: Mobil:8 “If cabin air becomes contaminated with any lubricant and / or its decomposition products, in suYcient quantities, some degree of discomfort due to eye nose and throat irritation could be experienced. Problems like these can be generally traced to improper design, improper maintenance or malfunctioning of the aircraft”. 1984: British Aerospace (BAe) Service Bulletin: SB 49-5, October 1984, “introduce an improved compressor inlet duct seal . . . inadequate sealing . . . allows fumes to be sucked from the bay area through the APU and into the passenger cabin. Compliance “information” CAA approval no.DAI/1011/55”. There are many such examples including those clearly listing oil leaks causing problems in the passenger compartment and air 9 supply system. 1990: BAe Service Information Leaflet: “Operators have been reporting an increasing number of hot oil smells in the passenger cabin”. 10 1984—Present: The British Aerospace BAe 146 regional jet has an extensive case history of oil contamination. The manufacturer has taken steps to address this since the aircraft entered service in 1984 for which there are now in excess of 200 forms of data to show the extent of the problem. These include manufacturer11 Service Bulletins, Service Information Leaflets, All Operator Messages, Airworthiness Directives and airline internal actions etc . . . Similar Service Bulletins date back to at least 1985 on the Boeing 757 such as the B757 Service Bulletin noting cabin air contamination during the B757 engines certification program. We have broken down the CAA failures on contaminated air events into the following examples: — Failure to accurately collate and acknowledge data; — Failure to enforce existing regulations; — Failure to address the underreporting problem; — Failure to investigate the scale of health eVects in crews; — Failure to stop industry misinformation; — Failure to investigate the presence of the organophosphate TCP in aircraft; — Studies of oils never tested via crew exposure route, notably inhalation; — Misinformation and errors in the 2004 CAA Cabin Air Quality paper; — Inappropriate use of exposure standards; — Failure to provide a medical protocol to deal with aVected crews and passengers; — Failure to ensure that passengers are informed if have been exposed; — Failure to acknowledge 100% certainty is not required to take preventative action; — Misinforming the public.

Example—Failure to accurately collate and acknowledge data

Following numerous reports of pilot and flight12 attendant impairment and ill health (short and long term) and reports of occasions when flight safety was being seriously compromised due to contaminated air events, the Australian Senate held a year long and very13 extensive inquiry in 1999 and 2000 specifically looking at the contaminated air problem on the BAe 146. The UK CAA was asked for their opinion, and responded to the Australian Regulator (CASA) and the Australian AAIB (ATSB) that they were unaware of crews becoming incapacitated or any related health issues. However, the CAA database of Mandatory Occurrence Reports (MORs) clearly shows they knew about these issues in the following “MOR” Examples: 1991: BAe 146—MOR No: 199103648: Passengers and crew suVered nausea and headaches/APU blowing oil/ Dan Air; 1996: BAe 146—MOR No: 199604940: Recurring fault/flight crew felt nauseous/eye irritation/oxygen used/ aircraft diversion undertaken;

8 Department, New York BAe Service Information Leaflet 21/27 28 September 1990. 9 10 Mobil (24 January 1983) Internal correspondence from E Ladov: Mobil Jet Oil Corporation, Environmental AVairs and Toxicology Events”; D Best, S Michaelis, Air quality in airplane cabins and similar enclosed spaces; Publisher Springer-Verlag GmbH, August 2005. 11 BAe Service Information Leaflet 21/27 28 September, 1990. 12 “Aircraft Air Quality Malfunction Incidents: Design, Servicing, and Policy Measures to Decrease Frequency and Severity of Toxic References Committee. Parliament of Australia. Final report, Canberra. 13 Rolls Royce RB.211-72-7651 service bulletin, February, 1985. SenateAustralia, of Australia Canberra. (2000) 1 November Air safety 1999. and cabin air quality in the BAe 146 aircraft. Senate Rural and Regional AVairs and Transport CASA and ATSB evidence to the Australian Senate Inquiry into Air Safety (1999–2000) BAe 146 Cabin Air Quality. Parliament of 3844421019 Page Type [E] 30-11-07 13:08:37 Pag Table: LOENEW PPSysB Unit: PAG4

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1997: B757—MOR No: 199705805: Very strong pungent oily smell in flight deck. Oily smell again very strong on flight deck during next departure but mild in cruise—during latter part of cruise both flight crew experienced sore eyes/throats and mild headaches. Subsequent medical examination confirmed that both flight crew members had been exposed to toxic fumes.

Example—Failure to enforce existing regulations

An aircraft is certificated based on a wide range of regulations. One of these is the ventilation regulation known as JAR (now EASA) 25.831 which states that: (a) Each passenger and crew compartment must be ventilated and each crew compartment must have enough fresh air (but not less than 10 cubic feet per minute per crew member) to enable crew members to perform their duties without undue discomfort or fatigue; (b) Crew and passenger compartment air must be free from harmful or hazardous concentrations of gases or vapors. To ensure an aircraft continues to be air worthy once it enters service it must through maintenance actions, continue to meet its design requirements. Despite the CAA being aware of a growing number of reported air quality problems on aircraft such as the British Aerospace BAe 146 and Boeing 757 it fails to take the action necessary to ensure the air quality remains to the standard outlined in JAR (EASA) 25.831 a & b. This is especially significant as the defect reports, MOR incident reports and other industry data clearly demonstrate that adverse eVects (undue discomfort & fatigue) are being felt by crews and consequently the compliance with the airworthiness requirement is not being met. Instead, they turn mostly a blind eye by rarely making the extensive number of Service Bulletins and other supporting data from the manufacturer which specifically relate to the issue of air supply contamination by engine oils into mandatory Airworthiness Directives. Rather they have simply allowed the operators to do as they please with the vast majority of modifications and inspections to address the problems (authorised by the CAA) being labeled as “for information only, optional or recommended”. Consequently, the travelling public and working crews are put at unnecessary risk. A risk the CAA themselves acknowledge they have not investigated as demonstrated below: 14 — House of Commons, 20 October 2004: CAA Aviation Health Unit advised it had not collated any information on symptoms from acute exposure to decomposition products in confined15 spaces. — House of Commons, 9 February 2004: The CAA advised it was “not aware of any adverse long-term health eVects in flight crew that can be traced back to the cabin environment”. — CAA Cabin Air Quality paper, 2004: “Although some references are made concerning long-term health eVects, the scope of this research did not include an attempt to determine the extent of any such risk”. The regulation (JAR 25.831a) clearly states that “each crew compartment must have enough fresh air . . . to enable crew members to perform their duties without undue discomfort or fatigue”. However, Mr Tom Hamilton, Head of CAA External Relations in a letter to BALPA dated 18 October 2004 is alleged to have stated: 16 “we do not agree with the interpretation that events ‘leading to discomfort’ should be considered a failure of JAR 25.831, unless there has been an adverse impact on ‘safe flight and landing’.” 17

Mr Dick18 Best a former CASA Airworthiness OYcer who issued the BAe 146-300 its Certificate of Airworthiness in Australia, strongly disagrees with the CAA interpretation of JAR 25.831 a/b. Additionally, Mr Stephen James, Head of Mechanical & Fluids Systems, SRG at the CAA, advised publicly in 2003 that: — CAA is “responsible for safety aspects, not longer-term health or comfort”; — When detailing JAR 25.831 part a) in a “PowerPoint” presentation this was misleadingly presented as only: “each passenger and crew compartment must be ventilated”; — The CAA is not responsible for events leading to crews feeling unwell or suVering irritation with no impairment such as nausea and headaches or irritation of the eyes, nose and throat.

14 15 16 17 Hansard House of Commons 20 Oct 2004 : Column 682W. 18 Hansard House of Commons 9 Feb 2004 : Column 1234W. CAA.or passenger Hamilton cabin. T letter to British Airline Pilots Association (BALPA) Aircraft Environment Task Group, October 2004. AOPIS Documentary: Contaminated Air: An Ongoing Health and Safety Issue (Available on DVD). CAA presentation by S James, SRG. BRE Cabin Air Conference September 2003. Flight deck occurrences from MORs compartment 3844421019 Page Type [O] 30-11-07 13:08:37 Pag Table: LOENEW PPSysB Unit: PAG4

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Given that globally various regulations and directives list fire explosion, smoke or toxic or noxious fumes as reportable incidents, it is clear that the CAA is misinterpreting the mandatory airworthiness legislation of JAR (EASA) 25.831 a). The CAA is consistently selectively ignoring the words “discomfort and fatigue”. The CAA interprets that pilots and cabin crew experiencing discomfort from headaches, nausea, irritation of the eyes, nose and throat irritation are having no impairment. Common sense tells us that a pilot performing under the above conditions will have some degree of impairment / eVect on eYciency to duties, yet not all eVects might be reported. The less serious eVects such as headaches, nausea and discomfort ought not to be passed oV by the CAA as “comfort issues” for which they have no responsibility20 as they may have long term health implications. The CAA itself has acknowledged that “contamination of the ventilation systems by engine oil fumes was the most likely cause of the reported problems” and “subsequent CAA investigations found no weight of evidence indicating that other causes were involved”. The CAA ought to be responsible for all situations that do or could have an impact on all stages of a proposed flight. The extensive database being currently collated by AOPIS as well as the CAA’s own MOR database, certainly show there is an extensive list of incidents showing discomfort is occurring and most incidents are not reported. 21,22 In contrast having learnt from the 2000 Australian Senate Inquiry, the Australian regulator CASA now sates that all events of smoke, toxic or noxious fumes inside the aircraft are considered as a major defect and therefore in all cases reportable to the regulator. This is irrespective of whether or not the reported considers his/her or the crew’s performance may have been impaired or not.

Example—Failure to address the under-reporting problem 23 24 Numerous groups including AOPIS have reported to the CAA that contaminated air events were seriously being under reported as acknowledged by the Australian Senate Inquiry and by the BALPA 2002 survey. Rather than act as we believe the CAA should have, the CAA confirmed its lack of interest in a letter from Mr Tom Hamilton to BALPA.12 The AFAP survey, the BALPA survey and the Australian Senate Inquiry clearly acknowledged that contaminated air events were being under reported. Despite AOPIS telling25 the CAA that less than 10%, at best, of the lower intensity contaminated air events20 were being reported due to crew pressure26 and lack of education, the CAA have done little to encourage crews to report these events. The CAA claimed that fume events were very rare and occurred at the rate of one per 22,000 flights yet the BALPA 2002 survey information shows this figure to be grossly incorrect. The CAA claim events are decreasing when in fact reports to AOPIS clearly show the opposite. Crews have sadly had to accept contaminated air events as part of the normal working environment due to the CAA’s failure to act. An acceptance partly27 due to over 20 years of inadequate responses to this problem by the regulator, the CAA. A position the CAA sit quite happily with as Mr. Hamilton stated “The CAA did not have any evidence of under reporting from air crews and that the existing reporting arrangements appeared to be working satisfactorily”.

Example—Failure to investigate the scale of health effects in crews 28 There are a growing number of crews reporting short and long term health eVects following contaminated air events, supported in many cases by extensive medical documentation from their doctors related to exposures to contaminated air by crews who fly the BAe 146, Emb145,29 B757, A320, B737 and other types. There is a long list of published papers from medical and scientific experts globally who have seen crews after these fume events. The CAA has previously advised that it was not appropriate for it to seek the views of crew’s medical experts familiar with this subject or other interested parties. Some of the findings presented at the BALPA conference showed clear parallels with Gulf War Syndrome, exposure to sheep dip and other

19 20 21 22 Directive 2003/42/EC of the European Parliament and of the Council, 13 June 2003—Occurrence reporting in Civil Aviation. 23 CAA Cabin Air Quality paper, 2004. CASA(2000) Air (2001) safety Defect and cabin reports air, civil quality aviation in the BAe advisory 146 aircraft. publication Senate 51–1(1). RuralCivil and Regional Aviation A SafetyVairs and Authority Transport of Australia, References Canberra. Committee. AustralianParliament Parliament of Australia. Hansard, Final report, Q3011: Canberra. Air safety—Cabin air quality, 29 March, 2004. 24 “The Committee also notes the strong evidence of a tendency of pilots to under-report incidents of this nature”. Senate of Australia 19:253–261. 25 26 Michaelis S (2003) A survey of health symptoms in BALPA Boeing 757 pilots. J Occup Health Safety, Australia and New Zealand Tom Hamilton of the CAA to BALPA, Aircraft Environment Task Group, October 2004. 27 Minutes from the 26th meeting of the AHWG of 27 October 2004. 28 CAA: “Recent data now demonstrates a much lower MORs reporting rate among the 2 aircraft fleet”(BAe 146 /B757). Letter from Conference” (2005) Held At Imperial College, London, 20-21 April 2005: ISBN 0-7334-2282-9. 29 Minutes from the 26th meeting of the AHWG of 27 October 2004. Proceedings Of The BALPA “Contaminated Air Protection Air Safety And Cabin Air quality International Aero Industry

Hansard House of Commons: 27 April 2004 Column 888W Tyler. 3844421019 Page Type [E] 30-11-07 13:08:37 Pag Table: LOENEW PPSysB Unit: PAG4

110 air travel and health: evidence organophosphates. Why has the CAA never taken the initiative to see the extent of medical eVects in crew members?30 When,31 the CAA Chief Medical OYcer suspended a pilot’s medical certificate in 2000 based on the view of his consulting neurophysiologist that the pilot “may be suVering long-term exposure to organophosphate chemicals” and that the pilot “may be suVering from some sort of chemical exposure in the BAe 146”, why did the CAA not investigate the scale of the problem? If the CAA had taken a deeper look in to the problem it would have found what we have found. AOPIS has found that crews are showing lung and neurological problems resulting in their medical certificates being suspended. 32 Much of this information was again confirmed by leading medical experts at the 2005 BALPA conference on contaminated air which we co-sponsored. Despite26 the conference showing even more new data the CAA advised there was no new information presented and the data available was inconclusive and unsupported. The failure of the CAA to even acknowledge the BALPA Conference findings just shows the extent of industry influence. When asked in the House of Commons why the CAA had not contacted the specialists who were aware of the eVects being experienced by crew, they replied that the CAA research to date “was a specific piece of research and therefore it was not appropriate for the CAA to seek the views, either from medical experts or other stakeholder”.11

Furthermore, the Minister of Transport27, advised 26 Paul Tyler MP on 9 February 2004 in the House of Commons that “The CAA is not aware of any adverse long-term health eVects in flight crew that can be traced back to the cabin environment.” It would appear that the CAA had forgotten that it had suspended a BAe 146 pilot’s medical certificate in 2000.

Example—Failure to stop industry misinformation

In 2003 the head doctor at British Airways, Dr Mike Bagshaw, stated in a communication to all its cabin crew members that: — TCP is a toxic mixture that can cause a wide array of transitory or permanent neurological dysfunctions33 when swallowed. However, there have been no recorded cases of neurological harm in humans following dermal or inhalation exposure. This means that the substance can be potentially harmful if swallowed in large enough quantity, but is not harmful if absorbed through the skin or breathed in.” 34 A statement no doubt aimed at making crews believe it was safe to breathe contaminated air, yet the main international NTP Chemical Repository Data for TCP clearly shows Dr Bagshaw’s comment to be inaccurate: — Acute/chronic hazards—This compound is toxic by inhalation, ingestion or by absorption through the skin. It is an irritant of the skin and eyes. It is also an irritant of the mucous membranes and respiratory tract. When heated to decomposition it emits toxic fumes of phosphorus oxides. — Emergency procedures—Inhalation: Immediately leave the contaminated area; take deep breaths of fresh air. Immediately call a physician and be prepared to transport the victim to a hospital even if no symptoms (such as wheezing, coughing, shortness of breath, or burning in the mouth, throat, or chest) develop etc . . . The Material Safety Data Sheet (MSDS) for the jet engine oil BP 2380 dated 1 January 2001 also states: 8Combustion Products: Toxic fumes may be evolved on burning or exposure to heat. Inhalation: At normal ambient temperatures this product will be unlikely to present an inhalation hazard because of its low volatility. May cause irritation to eyes nose and throat due to exposure to vapour mists or fumes. May be harmful by inhalation if exposure to vapour mists or fumes resulting from thermal decomposition products occurs. How can the CAA allow such misinformation to be allowed, particularly when it and similar information is being disseminated by aviation medical departments and CAA appointed Aviation Medical Examiners?

30 Captain J Soddy CAA ref 208050H. 31 CAA—11Dr M Fisher. December, Aviation 2000. medical Dr S adviser, Janvrin, Heathrow the Chief Airport. Medical CAA OYcer ref of 208050H. the CAA Safety Regulation Group, medical division letter to 32 33 CAA—11 December, 2000. Dr S Janvrin, the Chief Medical OYcer of the CAA Safety Regulation Group, medical division letter to Crew News; Issue 42–03, October 24. 34 Minutes of the AHWG meeting No 30 of 28 April 2005. Comments by Dr Ruge of the CAA AHU. Dr Mike Bagshaw (former Chief Medical OYcer British Airways/now Director Aerospace medical Association). British Airways Cabin

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Example—Failure to investigate the presence of the organophosphate TCP in aircraft 35

At the BALPA conference of 2005, evidence was presented that the organophosphate TCP was being found on the walls of BAe 146 aircraft, a BAe 146 pilot’s trousers, B757 dust and HEPA aircraft filters. The CAA has done nothing to discuss these findings with AOPIS, BALPA or ECA to the best of our knowledge, nor has it investigated these matters further despite this being a serious risk to public and crew health. In 2006 and 2007 100 percent of UK swab tests were positive for TCP.

Example—Studies of oils never tested via crew exposure route, notably inhalation

The CAA is aware that contaminated air events occur and that toxicological research on the eVects of inhalation of the pyrolysis products of jet engine oils and hydraulic fluids has never been done. Research undertaken on the36 eVects of the oils and its components to date have relied upon studies on rats and hens via oral ingestion of the unheated product with the toxicity referenced solely to the extreme medical condition known as OPIDN. OPIDN37 toxicity is not being described by crews. The toxicity which seems to38 be aVecting crews is OPICN but this has never been investigated. The CAA ignorantly assume that OPIDN ingestion toxicity of an unheated product is the same as OPICN toxicity via inhalation exposure to pyrolised engine oils and hydraulic fluids. It is well reported that inhalation exposure is more toxic than ingestion.

Example—Misinformation and errors in the 2004 CAA Cabin Air Quality paper 39 The CAA 2004 research paper which no crew body such as IFALPA, AOPIS or BALPA or any independent medical doctor or scientist had any input on, had over 50 errors in it which BALPA highlighted to the CAA in a letter dated 2 April 2004 and apparently still await a full written reply over 18 months later. Even though the correct toxicological testing has never been done, the 2004 CAA cabin air quality paper relies heavily on flawed data and deliberate misinformation to say the oils are not toxic. The CAA paper states that no single40 component or set of components identified in the BAe paper listed as Marshman S J. Analysis of the thermal degradation products of a synthetic ester gas turbine lubricant, DERA/FST/CET/ CR010527 (2001), marked: Commercial Restricted—Proprietary41 Information, could definitely cause the symptoms reported by crews. The CAA paper incorrectly states that the TOCP isomer of the organophosphate TCP (present in the oils at about 3%) is the most toxic isomer.42 This is not the case. The most toxic isomer of TCP is MOCP. The paper which was prepared by the DSTL for the CAA completely ignores43 and fails to mention anywhere that the more toxic isomers in the TCP, notably MOCP and DOCP are present. MOCP and DOCP are in synthetic jet engine oils according to Mobil at significantly higher quantities than44 TOCP and have been known for over 40 years to be 10 and five times more toxic than TOCP. Reliance on a BAe paper, subject to legal privilege and exempt from public disclosure, to say the air quality in BAe 146 aircraft is satisfactory is highly inappropriate. This is hardly an independent or objective way of investigating the issue. Compare this attitude to the US Federal Aviation Administration who launched in July 2005 a two year US$2 million funded research project and invited independent universities as well as labor representatives to participate in. Its worth pointing out the FAA have invited the UK AHWG and CAA AHU to be part of this project at no cost to the UK tax payer, but this has to date been declined. How the CAA can decline to be part in a no cost scientific exercise to find out for the first time what contaminants are present in a contaminated air event is inappropriate and should be investigated.

35 Contaminated Air Protection Conference, Imperial College London, April 2005. 36 ProfessorAugust 2003. C Van Netten. Aircraft air Quality Incidents, symptoms, exposures and possible solutions. Presentation made at BALPA 37 ProfessorJournal ofToxicology Mohamed Abou-Donia,& Environmental Organophosphorus Health, part B,1999—“Little Ester-Induced is known Chronic of the Neurotoxicity, absorption, distribution, Archives of retention Environmental or metabolism Health, of aryl phosphate esters after inhalation of mists or vapours. For the purpose of evaluating risks the simplifying assumption that Craiginhaled P, and Barth ingested M, Evaluation doses of aryl of the phosphate hazards of ester industrial are of equivalent exposure to toxicity TCP: A was review employed”. and interpretation of the literature. 1999 Mobil 38 39 40 41 AOPIS DVD, Contaminated Air—An Ongoing Health and Safety Issue. BALPAQuality Incident letter tos Dr (uc). A DSTL/ Ruge, CAA TR01591 Aviation (2001). Health Unit, 2 April 2004. 42 CAA PAPER 2004/04, Cabin Air Quality. Jenner,November J, Jugg, 1999. B, Scawin, J, Osmond, N, and Rice, P, The Toxicity of Aircraft Lubricant Pyrolysis Products Related to Cabin Air 43 Mackerer,engine oil containing C R, E Ladov, TCP”, N MobilBusiness USA Submission resources, to 1999— the AustralianJournal of Senate Toxicology Inquiry and into Environmental Air Safety—BAe Health. 146 Cabin Air Quality, 44 Mackerer C, Barth et al “Comparison of neurotoxic eVects and potential risks from oral administration or ingestion of TCP and jet

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Example—Inappropriate use of exposure standards 45,46,47,48,49,50 The CAA are referencing contaminant levels, in non contaminated air events, to inappropriate exposure standards which are not applicable at altitude or in aircraft environments. The CAA forget that synthetic jet engine oils and many of the chemicals present during a contaminated air event have no published exposure standards as these have never been researched. In comparison41 to the CAA eVorts to use inappropriate exposure standards, the RAAF have stated that “the aircraft cockpit and cabin are unique workplaces that cannot be compared with industrial and other workplaces on the ground and that the exposure standards used for industrial workers cannot be applied to aviation”.

Example—Failure to provide a medical protocol to deal with affected crews and passengers Crews are presenting to doctors for treatment following a contaminated event, yet these doctors and medical staV do not know how to deal with these issues as they are specialist issues and yet the CAA has failed to oVer any structured medical protocol or guidance to doctors, passengers or aVected crews.

Example—Failure to ensure that passengers are informed when they have been exposed 51 Airlines around the world do not tell passengers when they have been exposed to contaminated air events, despite the UK Government informing the House of Commons that while the pilot was not trained to identify specific chemical contaminants; “The captain has discretion to inform passengers of an event”. However, AOPIS members in the UK have been told by their employers that they should not tell passengers they have been exposed unless they ask for medical treatment. This must surely be gross negligence as how are passengers expected to get treatment if they have not been told. Most passengers will assume the air is safe and any contaminants they are exposed to are harmless despite the 2005 BALPA conference attendees being told that pregnant passengers were most at risk. The CAA should request airlines to tell passengers they have been exposed to contaminated air.

Example—Failure to acknowledge52 100% certainty is not required to take preventative action 53 A CAA spokesperson stated for a media article that: “Before people say anything is harmful, it should be proven scientifically” and that “There cannot be regulation on anything without scientific54 proof”. Some believe that “scientific uncertainty is inevitable in designing disease prevention programs and the search for absolute scientific proof is counterproductive and futile with scientific uncertainty being used as a tool by opponents of regulation to protect public health that may cause financial diYculty”. In view of the wealth of information linking contaminated air events and health issues surely the CAA should comply with the EU precautionary guideline that states:

Precaution Principle: European Commission, COM (2000) 1 “The use of the precaution principle presupposes that the potential dangers of a phenomenon, a product or a process have been identified and that the scientific evaluation doesn’t allow to establish the risk with suYcient certitude” or “The use of the precaution principle presupposes: — the identification of potentially negative eVects as a result of a phenomenon, a product or a process;

45 Smoke & Fumes. 46 DrASTM Bhupi 2000. Singh, Senior Research OYcer, AVMED, RAAF Edinburgh, SA, (2004) Australia Aviation Safety Spotlight 0304: In Flight 47 Fox2002. R, Air Quality and Comfort Measure Aboard a Commuter Aircraft and Solutions to Improve Perceived Occupant Comfort Levels 48 “TheNew Zealand Toxicity 1998, of Commercial 14 (2) 107–110. Jet Oil” Chris Winder and Jean-Christophe Balouet, Environmental Research, Section A 89, 146–164, 49 50 Associate Professor C Winder “Misuse of the exposure standard concept” Journal of Occupational Health and Safety Australia and 51 52 EH40/2000—HSE Occupational Exposure limits 2000. 53 Aviation Contaminated Air Reference Manual (2007) Susan Michaelis ISBN 978-0-9555437-0-8. 54 Hansard House of Commons 7 December, 2004 Vol 428, Col 420W Tyler. HeathrowEnergy’s Assistant Skyport, Secretary 6 May 2005. for Environment, Safety and Health from 1998 through January 2001. Dr Michaels is Research Professor Heathrowand Associate Skyport, Chairman 20 May in the 2005. Department of Environmental and Occupational Health (EOH) at the George Washington University MichaelsSchool of D, Public 2005 Health “Manufacturing and Health uncertainty” Services). American Journal of Public Health Supp 1 Vol 95 No S1 2005 (US Department of 3844421019 Page Type [O] 30-11-07 13:08:37 Pag Table: LOENEW PPSysB Unit: PAG4

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— a scientific risk evaluation which, owing to data insuYciency, of their non-conclusive character or their imprecision, doesn’t allow the risk with a suYcient uncertainty.”

Example—Misinforming the public 55 The CAA by way of Dr A Ruge, former head of the Aviation Health Unit stated in a letter dated 12 July, 2005 that “The results of the various research projects did not suggest that there is a health risk for passengers, including infants, or crew”. This statement contrasts with the CAA statement in their 2004 Cabin Air Quality paper of “although some references are made concerning long-term health eVects, the scope of this research did not include an attempt to determine the extent of any such risk”. Dr Ruge’s statement also contrasts with the conclusions drawn at the 2005 BALPA conference which stated: — There is a workplace problem resulting in chronic and acute illness amongst flight crew (both pilots and cabin crew); — The workplace in which these illnesses are being induced is the aircraft cabin environment. This is the resulting in significant flight safety issues, in addition to unacceptable flight crew personnel health implications; — Further, we are concerned the passengers may also be suVering from similar symptoms to those exhibited by flight crew”.

The CAA advised the House of Lords in 2000 that it is focused on air safety56 and is not concerned with crew general or longer-term health unless there is an impact on pilot medical certification. Additionally the CAA stated it had no direct responsibility of passenger health or comfort. At the same time the HSE also had no active responsibilities in relation to the health of airline passengers or crew. Are the CAA capable of the task whilst being funded by industry? We believe issues of health and safety should not be funded by the industry the CAA seeks to regulate. We also believe that a complete independent public investigation into the issues of contaminated air should be actioned as a matter of urgency to protect crew and public health. The current COT research is not independent, not open to open public review, meeting minutes are not accurate, information is misrepresented, the public are not allowed to speak at meetings etc. Filtration systems exist that could be fitted at low cost (£10,000) to protect the travelling passengers and crews. However, this would need action on the part of the CAA, not the continued denial and protective attitude towards the British Aerospace industry, notably the BAe 146 aircraft. 8 June 2007

Memorandum by the Boeing Company Boeing is pleased to submit evidence to the Science and Technology Committee in support of its inquiry into the progress made in the aircraft cabin environment since issuing its Air Travel and Health Report in 2000. This response includes a discussion of cabin environment features on current Boeing production aircraft, enhanced cabin environment features on new products, and ongoing standards and research activities within which Boeing is engaged.

GeneralInformation Boeing is the world’s leading aerospace company and the largest manufacturer of commercial jetliners and military aircraft, with capabilities in rotorcraft, electronic and defence systems, missiles, satellites, launch vehicles and advanced information and communication systems. Our reach extends to customers in 145 countries around the world, and we are the number one US exporter in terms of sales. Headquartered in Chicago, Illinois, USA, Boeing employs more than 153,000 people in more than 67 countries. Boeing has a long standing relationship with the UK dating back almost 70 years and today the UK remains a critically important market for the company, as a supplier base and a source for technology partners. Boeing’s annual spend in the aerospace industry supports thousands of jobs around the UK, in the process generating intellectual property and facilitating exports. Boeing sources more from the UK than from any other country in the world, except the USA. In 2005, the company bought more than $1 billion of services and materials from around 300 UK suppliers. There are currently more than 600 Boeing UK employees, in locations from Glasgow to Dorset.

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BoeingCommercialAirplanes

Boeing Commercial Airplanes (BCA) is the world leader in commercial aviation because of its complete focus on airplane operators and the passengers they serve. Boeing products and services deliver superior design, eYciency and support to airline customers and allow passengers to fly where they want to go, when they want to go. By working together with supplier partners from around the world, Boeing has delivered more than 15,000 airplanes to customers worldwide including airlines, leasing companies, governments and private firms. Boeing Commercial Airplanes is headquartered in Renton, Washington, under the leadership of President and Chief Executive OYcer Scott Carson. It is organised into three primary business units—787 Program, Airplane Programs and Commercial Aviation Services—as well as providing Airplane Trading services.

CabinEnvironmentFeatures

Cabin environment features on current Boeing production aircraft include: HEPA filtration for recirculated cabin air is basic equipment on all Boeing production aircraft. These filters capture 99.97% of particles 0.3 microns in diameter. For aircraft application, the most penetrating particle size is in the range of 0.1 to 0.2 microns. Capture eYciency exceeds 99.97% for particles larger than 0.3 microns and smaller than 0.1 microns. HEPA filters are an eVective means to prevent the spread of airborne bacteria or viruses via the air distribution system. Ozone converters for outside air are basic equipment on the Boeing 777 and 747-400 Freighter aircraft, and are optional equipment on the Boeing 737 and 747-400 Passenger aircraft. Ozone concentrations in the atmosphere vary with altitude, latitude, and season. Thus, the need for ozone converters is dependent on the time of year and routes the aircraft will operate. Since 2000, design improvement packages to reduce flight deck noise have been implemented on the Boeing 737 and 747-400. Additional improvements were made to the 737 to reduce aft cabin noise levels. Total ventilation rate results in an air change rate of 20-30 times per hour (compared with an air change rate of 4-10 times per hour in a typical building). The high air change rate in the cabin facilitates rapid removal of airborne particulate matter. Personal air outlets (PAOs) are basic equipment on the Boeing 737, and are optional equipment on the 747 and 777 aircraft. PAOs provide an eVective means for passengers to control their personal environment. Boeing has worked, and continues to work, with leading university and industry researchers to better understand the multiple factors that influence comfort and health-related symptoms experienced by passengers and crew in aircraft cabins. We are dedicated to expanding our knowledge, as well as improving our products. We continue to conduct research on cabin environment multiple factors that aVect passenger and crew comfort. Enhanced cabin environment features on the Boeing 787 will include HEPA filtration for recirculated cabin air and will remain basic equipment for all new products. Ozone converters for outside air will be basic equipment for the Boeing 787, as well as the 747-8 Passenger and Freighter aircraft. These aircraft will fly polar routes at high altitudes, thus increasing risk for exposure to high atmospheric ozone concentrations. Gaseous air purification system for recirculated cabin air will be basic equipment on the Boeing 787. This system removes gaseous contaminants, odors and irritants. Research at the International Center for Indoor Environment57 and Energy at the Technical University of Denmark (DTU) demonstrated that the use of gaseous filtration results in a reduction of symptoms commonly reported by passengers and crew. This includes some dryness symptoms typically associated with low humidity and irritation of the respiratory tract. The ventilation system controls on the Boeing 787 will allow the outside air ventilation rate to be adjusted per flight based on passenger loading. This capability reduces fuel burn, and maintains higher relative humidity in the cabin. The research conducted at DTU demonstrated that the combination of increased humidity and gaseous purification provide preferred cabin air quality.

57 hour Flights”, Proceedings of Healthy Buildings 2006. Reference: P Strom-Tejsen, et al“EVects of Gas Phase Adsorption Air Purification on Passengers and Cabin Crew in Simulated 11- 3844421020 Page Type [O] 30-11-07 13:08:37 Pag Table: LOENEW PPSysB Unit: PAG4

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Maximum cabin pressure altitude will be set58 at 6,000 feet on the Boeing 787. Research at the Oklahoma State University Center for Health Services demonstrated a reduction in cerebral/respiratory symptoms and muscular discomfort after three to five hours of exposure to a pressure altitude of 6,000 feet compared with exposure to a pressure altitude of 8,000 feet. The Boeing 787 will have a no-bleed architecture for the outside air supply to the cabin. This architecture eliminates the risk of engine oil decomposition products from being introduced in the cabin supply air in the rare event of a failed engine compressor seal. In addition, this architecture improves fuel eYciency, thus reducing fuel burn and associated engine emissions. Personal air outlets will be basic equipment on the Boeing 787. This includes nozzles at passenger seats, at attendant workstations in the galleys, and at attendant seats. The Boeing 787 will feature an advanced flight control system. The system can detect and react to vertical gusts associated with light and moderate turbulence. The reduction in vertical aircraft displacement will reduce the number of occupants who experience motion sickness. Boeing has set aggressive cabin noise level targets for the 787. Targeted noise levels are less than existing in- service aircraft. Boeing continues to support and is actively engaged in standards and research activities, including the following: American Society of Heating, Refrigeration and Air Conditioning Engineers (ASHRAE) Standard 161P for Air Quality within Commercial Aircraft. ASHRAE Research Project 1262. This project includes cabin environmental measurements, and collection of passenger and crew subjective responses, on over 160 commercial airline flights. The research will examine the link between aircraft cabin air and other factors to comfort and health related symptoms experienced by passengers and crew members. 59 Federal Aviation Administration (FAA), Center of Excellence (COE), Aircraft Cabin Environment Research (ACER) Team. Established in 2004, the FAA COE ACER Team is engaged in the several research activities, including: — impacts of ozone in passenger cabins; — exposure and risks of pesticides in aircraft cabins; — impacts of reduced pressure in aircraft cabins; — bleed air contamination incidents; — development of CFD tools to simulate contaminant transport in aircraft cabins; — evaluation of environmental air quality (EAQ) and chemical/biological sensors; and — evaluation of technologies for aircraft decontamination. In summary, the Boeing Company is committed to providing a safe, healthy and comfortable cabin environment for passengers and airline crews. Conclusion Boeing is committed to maintaining high standards in the provision of cabin environment features on all its commercial airliners. Boeing is also constantly developing new ways of improving the cabin environment and enhancing the passenger experiences. Many innovative features aimed at improving the cabin environment can be seen on the Boeing 787, such as increased cabin humidity, higher cabin pressure and gaseous air purification systems. 18 June 2007

Memorandum by the British Airline Pilots Association (BALPA)’s Occupational Health & Safety Group

Introduction The BALPA Occupational Health & Safety Group is a specialist focus group within the Association, whose remit is to deliver Health & Safety guidance and improvements for members, to train and support its Health & Safety Representatives, and to represent the occupational health & safety interests of its pilot and flight engineer members. This currently represents some 10,000 flight crew members in the UK.

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The BALPA Occupational Health & Safety Group consists of current operational pilots who have received training in accordance with accredited standards, including some holding post-graduate level qualifications in Occupational Health & Safety Management and membership of the Institute of Occupational Safety & Health (IOSH) Aviation Specialist Group Committee. The Group meets regularly with Airlines and Regulators— both the Civil Aviation Authority and Health & Safety Executive—in a variety of forums.

AirTravel andHealth

The identification, management and communication of health risks in air travel are of paramount importance and have are in significant need of further funding and a renewed stakeholder commitment, if the industry is to demonstrate that it regularly achieves what could be deemed best practice. It is very much our belief that such funding and investment must also provide for varied research projects into the various aspects of air travel on a cross-industry basis which includes all stakeholders and that a new culture of openness and sharing of health information is needed to provide that which an increasingly interested public expects. We agree with the Committee’s comments in Para 1.8 that health has been “woefully neglected”, and in particular we wish to record our concerns regarding the trends in increasing risk and pressure suVered by flight crews due to lengthening duty periods as a result of increasing delays, allied to ever reducing rest periods between flight sequences in airline eYciency drives, whilst still attempting to maintain the highest of standards in ever more densely crowded skies. There is a need for a review of the fundamental applications of crew fatigue and stress management standards being applied to flight crew—for too long the perception that pilots are able to cope with all forms of adversity has been an accepted industry norm—and this culture needs to change. It is a culture which promotes acceptance of excesses of stress, and re-enforces a lack of fatigue reporting through concerns over job-security. Quite rightly over the last half-century, the aviation industry has focused its eVorts on the primary provision of flight-safety, but this now needs to be augmented with a new determination to govern and protect the health and safety of the individual crew members who have provided this given. BALPA Occupational Health & Safety Group fully supports the recommendation of Para 1.9 and we endorse the view that the Government actively promote both the health of crews and passengers, as a specific goal in the immediate future. We also recognise the inertia referred to in Para 1.10 of the safety focused regulatory structures and recommends that the widespread knowledge available through bodies such as IOSH be fully utilised and integrated into new health & safety related management structures which now apply to aviation. The funding levels of the HSE and CAA SRG by Government are something which we believe needs urgent attention, with a significant injection of investment into each—to be ring-fenced specifically for health related issues.

BALPA’sResponse

With regard to Para 1.11—the European Working Time Directive in 2006, was the instrument responsible for the extension of UK Health & Safety Legislation (HASAWA 1974 etc.) to mobile transport workers, and until the implementation of this Directive under the Civil Aviation Working Time Regulations, flight crew had no recourse to Health & Safety legislation. In response to this, BALPA established its Occupational Health & Safety Group in November 2005, to provide both a service to its members and a focus point for engagement with other parties with an interest in the subject, including the relevant governmental and regulatory bodies, employers and fellow Trade Unions. The Group meets on a monthly basis establishing policy, setting goals, monitoring trends and to supply training. BALPA now has qualified H&S Representatives across a broad spread of UK airlines. The training of new volunteer reps and the ongoing professional development of existing Reps and members continues apace. However, the release of pilot H&S Representative volunteers to complete their training and to carry out their activities by some airlines—is a problematic issue. Some airlines still refuse release for these activities. Our belief is that this is partly due to resistance on the part of some airlines to accept that H&S legislation be applied equally to pilots as it is to ground based workers. Indeed, we find that we are often frustrated by the disapplication of certain specific legislation to flight decks—for example the Display Screen Regulations. The whole is far from satisfactory at present, leading to both delays and diYculties in the application of health and safety standards enjoyed by ground based staV. 3844421021 Page Type [O] 30-11-07 13:08:37 Pag Table: LOENEW PPSysB Unit: PAG4

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DeepVeinThrombosis (DVT) We support and are pleased to see that the Committee accept that DVT is an issue which is not solely confined to air travel. We believe that the additional risks in air travel only augment the overall risk of a DVT development in a minor manner and that the Department of Health, CAA and AOA should provide clearer, more uniform advice covering all forms of travel. With regard to the taking of health providing exercise on aircraft, we wish to record that the necessary locking of the flight deck door system post the 9/11 events, has led to a culture of pilots being stuck in a confined area with little opportunity to stretch and move the legs for significant periods of time. This may have longer term health implications.

AirQuality BALPA’s Occupational Health & Safety Group see no sensible reason for not adopting the JAA requirement for a fresh air only supply to the flight deck, and to this extent are at odds with the recommendation of the Committee. The pilots are the two singularly most expensive pieces of flight safety equipment on board and we believe that this status deserves recognition and that includes the provision of a fresh air supply. There may be other security related issues which further re-enforce this opinion. We do not concern ourselves with the view in some circles that this would imply that re—circulated cabin air is intrinsically bad, but add that scientific evidence suggests that on the whole cabin air is normally of acceptable quality—with occasional acute exceptions. The Committee is no doubt aware that BALPA along with DfT and several other key industry stakeholders are undertaking joint research into cabin air quality to establish further scientific facts.

Smoking We believe that the EU smoking ban in confined spaces from July 2007 be applied to all aircraft cabins operating within the boundaries of UK territorial airspace. We fully support no smoking legislation.

AirFiltration BALPA Occupational Health & Safety Group fully endorses the Committees recommendation regarding air filtration, and we urge all airlines to adopt a positive and pro-active stance towards HEPA filtration and accept that any improvements in filtration are cost-eVective in terms of crew and passenger health.

Noise BALPA continues to press for further flight deck noise research and for airlines to be responsible for providing adequate hearing protection for flight crew—both whilst in the aircraft and whilst exposed to noise hazards when carrying out external duties on the ground. Noise levels at the ear should be controllable to levels as defined under the Control of Noise at Work Regulations 2005. Noise induced hearing loss is both permanent and prevalent in the industry yet protection is easily aVordable. Sadly, we note that few UK airlines provide legally adequate levels of information, instruction and training along with personal protection equipment for pilots to be able to protect their hearing—which can lead to a loss of flying licence and hence career due to health failings. Whilst the causes of in-flight noise may be costly to rectify, the cost of suitable protection is reasonable and we continue to press all UK airlines to put into place adequate noise control programs for flight crew including the provision of suitable training.

Stress andFatigue With regard to stress our principle concern is to record the increasing levels of work-related stress felt by our members, with empirical evidence suggesting that rates of increase in stress are rising year on year. In our unique role the committee should appreciate that our stress is augmented by constant jet-lag and fatigue and that the industry poorly supports the health issues surrounding this situation. The Occupational Health Group at BALPA would like to see a review of flight crew scheduling and rest limitations to introduce systems which support more suitable rest breaks between flights and thus help to reduce chronic fatigue prevalence towards the latter stages of many long-haul flights. Additionally, we 3844421021 Page Type [E] 30-11-07 13:08:37 Pag Table: LOENEW PPSysB Unit: PAG4

118 air travel and health: evidence recognise that increasingly hectic short-haul work patterns for crews add to fatigue levels in a very stressful environment, and ask that this Committee recognise the need for research and serious review of planned rest patterns. Fatigue is cumulative, but our rostering systems assume that the tiredness counter in each pilot is reset to zero on the first day of each month and take no account of the previous months experiences. This is a potential flight safety hazard which needs a fresh approach. More eVort has to be placed through regulators into re-aligning crew rest periods with a proper regard to fatigue of crews during subsequent flights. We support more research in this area.

CosmicRadiationExposure This report, has quite surprisingly, made no reference to the eVects of cosmic radiation exposure of flight crews. Whilst much research has been conducted we feel that more is required. Indeed to this extent we have developed a methodology for an epidemiological study into flight crew schedules and exposure on various types of long-haul aircraft. Our concern is that the latest generation of ultra-long haul aircraft are able to climb shortly after take-oV to high cruise altitudes and remain at high altitudes for considerably longer than older aircraft types on whose performance much data is based. This allied to a trend towards increasing annual flying hours amongst long-haul crews is of concern to us. We wish to see the DfT to sponsor a major new research eVort into this field. June 2007

Memorandum by the Building Research Establishment (BRE)

Introduction BRE is a leading independent research and consultancy organisation and, amongst other activities, carries out a wide range of projects for the European Commission, national Government, and aerospace firms in the area of aircraft cabin environments. BRE is committed to improving the quality of the cabin environment for the benefit of all stakeholders. BRE is owned by BRE Trust, a registered Charity, whose objectives are through research and education, to advance knowledge, innovation and communication in all matters concerning the environment for public benefit. The Trust ensures that BRE remains independent of commercial interests, and safeguards BRE’s national and international reputation for objectivity and impartiality in research and consultancy.

BRE submitted evidence on ventilation provision in aircraft60 to the original inquiry in 2000 by the Committee on Air Travel61 and Health. Since that time, BRE has been considerably active in the field of air quality monitoring on board commercial revenue earning flights including those carried out under CabinAir (a European Commission Fifth Framework project), and the Phase 3 study for the Department of Transport. On this occasion we would like to comment on the original recommendations relating to air quality—specifically those relating to 1.26, 1.27, and 1.30

Evidence Recommendation 1.26 calls on airlines to carry out cabin air sampling programmes from time to time, and to make provisions for spot-sample collection in the case of unusual circumstances. It is our view that: — The issue of cabin air quality remains as pertinent now as it was then; — Equipment for carrying out general air quality monitoring on board revenue-earning flights has been developed. However, lack of demand from airlines has meant that oV-the-shelf equipment is not generally available; — Collecting spot-samples during “unusual” circumstances has proved to be diYcult. However, BRE is well advanced on this aspect. It is our understanding that the Department for Transport will be addressing this as a result of the Committee of Toxicity’s considerations on “cabin air environment, ill-health in aircraft crews and the possible relationship to smoke/fume events in aircraft”. Recommendation 1.27 welcomed the ASHRAE work on cabin air quality standard. The Committee may wish to note that:

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— The US ASHRAE Standard is not yet published and is awaiting approval from the ASHRAE Board of Directors; — The European preStandard prEn 4618 “Aircraft internal air quality standards, criteria and determination methods” was published in September 2004. This was a direct outcome of the BRE co-ordinated European CabinAir project (mentioned earlier) and the preStandard was prepared by AECMA-STAN (now ASD-STAN)—a CEN Associated Body which produces standards for aviation. This standard is the first of its kind for indoor air quality and thermal comfort in commercial passenger aircraft. Recommendation 1.30 asks airlines to review and modify their cabin design considerations to include air nozzles under personal control in newer aircraft. We note that: — In general, newer aircraft do not appear to have these air nozzles; — Our view is that air nozzles do provide a perception of “fresh” air to occupants, and that this recommendation is still as valid now as it was then. 20 June 2007

Memorandum by Dr Clement E Furlong Comments related to the exposure to tricresyl phosphate during engine seal failure incidents.

A very brief history of tricresyl phosphate research

Following the cases of paralysis resulting from the adulteration of ginger extracts during the prohibition era in the United States,62 research readily identified the ortho isomer of tricresyl phosphate (TCP) as the chemical responsible for63 the paralyses. It is remarkable that at the time that Henry Ford was manufacturing the Model A Ford, scientists were able to so readily identify the ortho isomer of TCP as the agent responsible for the cases of paralysis.64 In the 1950s it became evident that metabolism of TCP was required to generate the toxic metabolite(s). In 1961, Casida and co-workers identified the active metabolite of TCP (Saligenin cyclic o- tolyl phosphate). It is this active metabolite that causes peripheral neuropathy via inhibition of neuropathy target esterase. While some safety considerations consider only the end point of peripheral neuropathy as being significant, many other physiological consequences can precede the delayed peripheral neuropathy. If these exposures are aVecting the cognitive capabilities and/or general health of pilots, crew and passengers, it is important to know this and take corrective measures to prevent these consequences of exposure.

65 Are aircraft occupants being exposed to TCP?

A recent report by van Netten documents the presence of TCP in a number of aircraft filters, the flight deck walls and a pilot’s trousers. He also describes the development of a small filter unit that can sample air for organics as well as CO. The unit is easily activated during an event. Prof. van Netten also notes the importance of biological monitoring. Incidence frequencies and incident associated symptoms are also reported.

Attendance66 at several cabin air quality conferences, where the question of whether or not individuals were exposed to TCP, prompted us to begin development of a blood test that could determine whether or not an individual was exposed to TCP. We carried out proof of concept experiments for identifying biomarkers of exposure. The proof of concept involved the modification of the active site of porcine liver carboxylesterase with TCP. The attachment of monocresyl phosphate to the active site serine was readily apparent with mass spectrometric analysis. TCP binds initially as a dicresyl phosphate to the active site serine, then “ages” to the monocresyl phosphor serine. We have begun the experiments to adapt this analysis to human blood samples. These analyses are underway and should be completed before the end of the year if not sooner.

62 26:976-992. 63 See,Simons eg, EGL. Smith, 1955. MI, Metabolism Lillie RD 1931. of triaryl Thephosphates histopathology in rodents, of tri-ortho-cresyl-phosphate Nature 176: 259–260. poisoning. Arch Neurol Psychiat, Chicago 64 65 Aldridge WN. 1954. Tricresyl phosphates and cholinesterase, Biochem J 56: 185–189; Myers DK, Rebel JBJ, Veeger C, Kemp A, 66 ForCompounds. a review see,Proceedings Glynn P of 1999, the BALPABiochem Air J, 344: Safety 625–63. and Cabin Air Quality International Aero Industry Conference, Imperial College, vanLondon, Netten 20–21 C 2005, April, J Occup 2005. Health Safety—Aust NZ 21:460-468. Furlong CE, Cole TB, MacCoss M, Richter R, Costa LG. Biomarkers for Exposure and of Sensitivity to Organophosphorus [OP] 3844421023 Page Type [E] 30-11-07 13:08:37 Pag Table: LOENEW PPSysB Unit: PAG4

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OtherPoints toConsider in yourReview

Other active TCP isomers

The ortho cresyl phosphate content of67 lubricants is often reported as the percentage triorthocresyl phosphate (TOCP), ignoring the content of the mono- (MOCP) and diortho (DOCP) isomers. Since the monoorthocresyl phosphate may be 10-times as active as TOCP and DOCP 5-times as active, it is important to consider the content of these isomers in products.

Synergistic effects of mixed exposures TCP is a potent inhibitor of carboxyl esterases, enzymes that are important in the detoxication of other insecticides. Casida et68 al. note the potentiation of malathion toxicity by TCP in their 1961 publication. van Netten (2005) points out the importance of carboxyl esterases in the detoxication of pyrethroid compounds in his recent paper. Dr Hodgson’s research team has shown that chlorpyrifos oxon exposure clearly potentiates permethrin toxicity. Our own recent research has looked at the potentiation of malaoxon toxicity by chlorpyrifos oxon, diazoxon and paraoxon as well as the modulation of this potentiation by genetic variability in the human PON1 gene (Jensen, unpublished results). Thus, spraying the cabin with what is thought to be a very safe insecticide may not be so safe if an individual has had a recent exposure to TCP, parathion, diazinon or chlorpyrifos.

Genetic and developmental factors affecting OP sensitivity

Another factor to consider in your review69 is the presence of highly susceptible individuals among pilots, crew and passengers, especially, the very young passengers or developing foetuses. Two of our recent publications deal with the increased sensitivity of the very young as well as individuals with genetically determined increased sensitivity to OP exposure. While much has been learned about genetic factors that aVect sensitivity to some OP compounds, there is still much to learn about the factors involved in determining sensitivity to specific OP compounds. I will be pleased to keep you informed on the progress of our research that is aimed at developing biomarkers of exposure to TCP. I hope that these comments are useful for your review. 18 June 2007

Memorandum by the Global Cabin Air Quality Executive (GCAQE) I have been investigating the contaminated air issue since 2001 when a fellow airline Captain called me and advised me how he had been exposed to toxic fumes in a British Airways Boeing 757 and asked me to investigate these issues. I am currently a non salaried co-chairman of the Global Cabin Air Quality Executive (GCAQE) which is “A global coalition of health and safety advocates committed to raising awareness and finding solutions to poor air quality in aircraft.” The GCAQE is the leading organisation globally representing air crew with regard to cabin air quality, specifically contaminated air issues and representing over 400,000 aviation workers globally in three continents. GCAQE members have been actively involved in working with crews, global experts, scientists, doctors and the aviation industry for many years on this subject, including being members of several international committees such as the FAA OHCRA project, ITF, SAE and ASHRAE committees. I have also published papers on the contaminated air issue and was responsible for providing all the evidence that was originally sent to the Committee on Toxicity (COT) for their investigations into the contaminated air issue. Sadly, many say the COT investigation is not only flawed but industry biased and I would agree. May I start my submission by highlighting that the contaminated air issue which is the basis of my submission is a highly political and industrial issue with many vested interests at stake. These vested interests frequently work to protect the airline industry from the massive financial cost which would be incurred if the issue was accepted for the serious health and flight safety issue it currently is, not just in the UK but worldwide.

67 of homologous phenols. Naunyn Schmiedebergs Arch Exp Pathol Pharmako, 1958;233(6):512–7, German. 68 HenschlerDrug Metabol D, Bayer Drug H.0H. Interact, 1958, 2004;20(4):233–46. Toxicological studies on triphenylphosphate, trixylenylphosphates and triarylphosphates of mixtures 69 ChoiExpression J, Hodgson of human E, Rose paraoxonase RL, Inhibition (PON1) of trans-permethrin during development, hydrolysis Pharmacogenetics in human liver 13:357-364; fractions by Furlong chloropyrifos C, Holland oxon N, and Richter carbary, R, Bradman A, Ho A, and B Eskenazi. 2006. PON1 status of farmworker mothers and children as a predictor of organophosphate Colesensitivity, TB, RL Pharmacogenetics Jampsa, BJ Walter, and TL Genomics, Arndt, RJ16:183–190. Richter, DM Shih, A Tward, AJ Lusis, RM Jack, LG Costa, and CE Furlong. 2003. 3844421024 Page Type [O] 30-11-07 13:08:37 Pag Table: LOENEW PPSysB Unit: PAG4

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The contaminated air problem has many dimensions which I will summarise as follows: 1. Crews under-report contaminated air events to the extent that less than 4% of events are actually reported in the first place. This is due to commercial pressures, lack of education and a lack of will within the airline industry to ensure all events are reported; 2. Crews that do report contaminated air events are rarely contacted by the AAIB and never contacted by the CAA medical section; 3. Last year the US FAA stated and finally agreed, that under-reporting of contaminated air events is occurring, yet the CAA remains in denial of the problem; 4. Aircraft have no detection equipment for contaminated air yet aircrews are not required to even have a sense of smell to be able to fly. Many compounds present in contaminated air are also odourless like carbon monoxide; 5. The breathing air for passengers and crews comes from “bleed air” in flight, which is taken from the engines. This is not filtered and is known to become contaminated with engine oils and hydraulic fluids; 6. A typical jet engine oil, BP2380 states on the MSDS that when heated the oils will give oV toxic fumes and that is what they are doing; 7. Airlines do not tell passengers they have been exposed to contaminated air and never check up with exposed passengers to investigate any medical eVects of exposure after an event; 8. Airlines fail to warn passengers of the serious health eVects that can occur from exposure to contaminated air; 9. Most passengers assume the air they breathe is free of hazardous chemicals as they trust the airline they fly with to supply clean air. Should they get sick, few if any ever make the link; 10. The CAA is entirely funded by the airlines it regulates. This results in a serious conflict of interest. This has resulted in the CAA dealing with the ongoing contaminated air exposure issue in a negligent manner. The CAA in this regard fails to protect the travelling public and working crews; 11. COSHH regulations are neither enforced by the CAA or the HSE; 12. The CAA lacks expertise in the area of contaminated air; 13. The 2004 paper by the CAA was seriously lacking in technical accuracy and would never have stood up to a peer review process. The paper was clearly written to protect the industry, not the travelling public and crews. No independent medical doctors or crews were contacted and asked to provide any input. The paper relies in part, on research carried out by BAe Systems which remains confidential and not available for public review. The CAA paper was a poor attempt to claim contaminated air causes no long term health eVects which they even acknowledge they have never investigated; 14. Serious failures in flight safety have resulted from exposure to contaminated air as few crews actually use oxygen when they suspect the air is contaminated as they ought to. The airlines and CAA know this, but do nothing to rectify this hazardous condition. Why? As to do so, would be costly to the industry; 15. Lip service is being payed to regulations regarding the reporting of contaminated air events or the airworthiness of an aircraft which is suVering from such events; 16. Filtration systems, detection systems and less toxic oils are all available today but the industry lacks the will or desire to take steps to protect the travelling public; 17. The Government and regulator who are entrusted to protect the public are in the eyes of many either protecting British industry (British Aerospace) or failing to enforce regulatory change. In 2000 the House of Lords Science and Technology Committee published its report Air Travel and Health. The report was technically flawed and very misleading in relation to the contaminated air debate. The report had numerous serious errors. Many industry submissions were inaccurate and can only be seen as attempts to mislead the Committee. This has allowed the airline industry and government departments to hide behind flawed data, an inaccurate report and resulted in further delay in addressing this ongoing health and flight safety problem. For instance, the report mentions on 18 occasions the chemical isomer of tricresyl phosphate (TCP), notably Tri-ortho-cresyl phosphate (TOCP). Yet the report amazingly fails to ever mention the other more toxic isomers in the TCP used by most commercial jet engine oil manufacturers, notably Mono-ortho-cresyl phosphate (MOCP) or Di-ortho-cresyl phosphate (DOCP). In doing so the report therefore under stated the 3844421024 Page Type [E] 30-11-07 13:08:37 Pag Table: LOENEW PPSysB Unit: PAG4

122 air travel and health: evidence toxicity of the ortho isomers of TCP by a factor of 6.14 million, based on their amounts present and relative toxicity as stated by Mobil to the Australian Senate in 1999 and in papers published by their head toxicologist also in 1999.

Why was Rolls Royce allowed to misinform the Committee by stating: “4.38 Rolls-Royce stated that all current TCP used in the formulation of aviation lubricants contained far less than 0.1% TOCP and that, in fully formulated oils, TOCP was at practically undetectable parts-per-billion levels (p 271).”

Why did Rolls Royce not declare the significant higher amounts of DOCP and MOCP?

Another example is as follows. The report stated: “4.37 TCP exists in three diVerent forms or isomers, of which the “ortho” form (tri-ortho-cresyl phosphate—TOCP) is highly toxic. As noted by the Medical Toxicology Unit and OPIN, the most significant adverse eVect of overexposure to TOCP, which might arise from improper use of the parent material such as swallowing or prolonged or repeated inhalation or skin contact, is peripheral neurotoxicity (nerve damage). This can lead to pain and serious paralysis of limbs, and bowel and lung disorders. After exposure ceases, some recovery usually ensues but a degree of permanent disability is not uncommon (pp 96, 257).”

This is totally untrue, TOCP is in fact the least toxic of the ortho isomers, with DOCP being five times more toxic and MOCP 10 times more toxic than TOCP itself. That was published in 1958. Also in 1958 it was clearly stated that it was totally inappropriate to only refer to TOCP toxicity and forget DOCP and MOCP toxicity which is exactly what the Lords report did. Secondly “peripheral neurotoxicity” can not be stated as the most significant adverse eVect of TOCP. All medical conditions resulting from exposure to contaminated air need to be looked at. These are well documented and range from chronic neurotoxic eVects to lung injuries. Many published papers outline doctors concerns in this regard. TCP is obviously part of the equation as it is a known neurotoxin. Swab testing of UK registered aircraft in the last two years has to date shown that 100% of tests were positive for TCP on the passenger walls, cockpit Boeing 757 roof top filters, HEPA filter analysis, pilots’ trousers and even in pilots’ blood. Additionally TCP exposure is now also linked to chronic neurotoxic eVects being seen in crews and confirmed by way of SPECT and PET scans. Soon a blood test allowing passengers to confirm TCP exposure and time of exposure will be available. This is research I as a former crew member had to finance to get started.

Another example of errors in the report are as follows. The report stated: “4.41 The absence of confirmed cases of TOCP poisoning from cabin air and the very low levels of TOCP that would be found in even the highly unlikely worst case of contamination from oil leaking into the air supply lead us to conclude that the concerns about significant risk to the health of airline passengers and crew are not substantiated.” and “4.39 Calculations by Airbus Industries (Q 461 and refined in subsequent correspondence) showed that the worst-case scenario of the total discharge of an engine’s lubricant into the engine would result in about 0.4 kg of oil passing into the cabin ventilation systems. Assuming that the oil contained 3% TCP, of which 0.1 percent was TOCP, the peak cabin atmosphere TOCP level would be about 0.025 mg/m3, reducing as a result of normal ventilation thereafter. The peak level would be a quarter of the workplace limit of 0.1 mg/m3 (and less than a tenth of the emergency workplace limit of 0.3 mg/m3). Contamination at much lower levels would result in visible smoke and odour which would normally result in the crew switching oV the ventilation feed from the aVected engine.”

These comments are extremely misleading as it is the eVect of exposure(s) to the complex chemical mixture that occurs during a contaminated air event that needs to be looked at, not single compounds. Exposure standards for this scenario do not exist. The exposure limit referenced by Airbus is for a pure compound, not for a mixture of chemicals. Exposure standards do not apply at altitude and only apply to workers in an eight hour shift, not to passengers or crews inflight. 3844421024 Page Type [O] 30-11-07 13:08:37 Pag Table: LOENEW PPSysB Unit: PAG4

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The issue of exposure to numerous chemicals simultaneously was addressed by Lord Davies of Oldham who was very clear on this matter when answering a question from the Countess of Mar:

“The Countess of Mar asked Her Majesty’s Government: What exposure standards currently apply to any synergistic eVects of simultaneous exposure to numerous chemicals which may be experienced by aircraft passengers and crew during a contaminated air event in a reduced pressure environment. [HL1761]

Lord Davies of Oldham: None. European airworthiness regulations for aircraft and engine design are written in objective terms that stipulate that the air provided to the passenger and crew compartments must be free from harmful or hazardous concentrations of gases or vapours.”

October 2005

Another example of errors in the report is as follows.

The report stated:

“4.40 This question, including the potential eVects on aircrew from any long-term exposure, has been looked at in much greater detail by a Committee of the Australian Senate inquiring into particular allegations of such contamination in the BAe 146. Although its Report 58 referred extensively to cabin air quality and chemical contamination in the aircraft, and recommended that the engine lubricating oil used (a Mobil product) be subjected to a further hazardous chemical review, it made no specific points about TCP or TOCP that have given us additional concerns.”

This is complete misinformation as it fails to highlight that the Australian Senate looked at the eVect of exposure to the cocktail of chemicals people are exposed to, not single compounds. May I remind you that the Australian Senate spent about 100 times more time investigating these matters than the Lords did and concluded that crews were being adversely aVected from exposure to contaminated air and described this as “Aerotoxic Syndrome.”

I could write a paper just on the House of Lords inaccuracies but I am sure you can see the points I am making. The important matter is to look forward and to what can be done today and in the future to protect passengers and crews from contaminated air exposures.

What I would suggest would be of most benefit to the House of Lords Science and Technology Select Committee would be to receive a presentation with questions and answers from the GCAQE, especially as the GCAQE is the leading crew group in the world on these matters. In fact I would say that there are three people who know this issue back to front in the world from a global perspective. Myself and two others. Susan Michaelis a former pilot and who called for the Australian Senate investigation in 1999 and who is the GCAQE researcher and author of the first ever Contaminated Air Reference Manual published in 2007. The third is industrial hygienist based in the USA called Judith Murawski who co-chairs the GCAQE with me and who also sits on the industry ASHRAE SPC-161 committee with me and industry representatives. Both Ms Michaelis and Ms Murawski have published numerous papers on these matters and made countless presentations around the world over the last 10 years.

I hope this frank submission will help the Committee realise the urgency with which these matters need to be addressed. I urge the Committee to allocate the time and resources appropriate to the seriousness of the issue at hand in relation to flight safety and public health. However in view of the limited time and resources at your disposal, I feel the only appropriate way of unmasking the corporate scandal contaminated air has become, would be by way of a Royal Commission which would allow the truth and facts to be voiced and revealed once and for all.

The only people saying there is no problem is the airline industry and those there to protect it. 13 June 2007 3844421025 Page Type [E] 30-11-07 13:08:37 Pag Table: LOENEW PPSysB Unit: PAG4

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Memorandum by the Health Protection Agency

Introduction The Health Protection Agency notes that the House of Lords Science and Technology Committee intends to inquire into air travel and health and in particular to look at developments since 2000 when it published its last report on this subject. The Agency was established in April 2003 and therefore did not contribute to the original report. However the parts of the report relating to new health concerns and the risk of transmission of infection now lie within the Agency’s area of statutory responsibility and we wish to take this opportunity to oVer our views to the Committee.

NewHealthConcerns The Agency is aware of no new or emerging health concerns that are specifically related to flying. We would distinguish between health concerns that are specifically related to flying and those where air travel might have an influence on the spread of a health hazard or aVect the course of a disease outbreak. Although SARS was perceived as an example of the latter threat when the original report was published, it is not currently seen as a significant global public health threat. The issues raised are now best considered in the context of a possible influenza pandemic, but with the benefit of learning from the global SARS experience.

Travel and theTransmission ofInfection The influence of air travel might arise in two ways: (1) the speed of travel by air, particularly for long distance travel, and (2) any unique quality of the aircraft that facilitated, or inhibited, spread of an infectious agent or other health hazard while on board.

Speed ofTravel The impact of the speed of long distance air travel (compared to land or sea) is that it might allow passengers to arrive at a destination while still infectious whereas those travelling by slower transport would have either recovered or succumbed before arrival. This has always been a risk as travel times reduced. The keys to reducing the risk are to discourage people from flying if they are unwell and to respond appropriately when ill passengers disembark. Within its pandemic influenza contingency planning the Government has developed advice on travelling in the period before a possible pandemic in line with WHO advice. Advice has also been produced for British nationals living abroad about travel arrangements in advance of a possible pandemic. Systems are in place within the aviation sector for port health authorities to be notified when an incoming plane has ill passengers on board so that appropriate arrangements can be made at the airport to receive and assess the passenger. These systems are activated for a number of illnesses and would be in place in the early stages of a possible pandemic. The potential impact of restricting travel on the evolution of a possible pandemic is considered later.

Transmission ofInfection Concerns about the transmission of infection during a flight centre principally on respiratory illnesses. As noted above the concerns initially focused on SARS but are now more often considered in the context of a possible pandemic influenza. The key questions focus on the method of transmission of an infection from one person to another in an aircraft and particularly on the relative contributions of large droplet and contact transmission versus aerosol spread. Aerosol spread, if it was a significant factor, would potentially result in wider spread in an aircraft. In general epidemiological studies suggest that the air systems within an aircraft are not conducive to the easy spread of infection through the aircraft. In those cases where on-board spread has been documented it has generally been restricted to the immediate environment of a sick passenger; similar risks would apply to other modes of travel apart from aircraft or indeed to close, prolonged social or domestic contact. 3844421025 Page Type [O] 30-11-07 13:08:37 Pag Table: LOENEW PPSysB Unit: PAG4

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With particular regard to a possible influenza pandemic, the HPA has examined the data upon which to base any judgement about modes of transmission of influenza virus within an aircraft. Currently there are multiple competing hypotheses, a lack of reproducible experimental findings and frequent extrapolation from experimental and animal models in scientific papers. Nevertheless, most data point towards short-range transmission in real-life settings and this pattern of transmission is known to be associated with spread by large droplets and contact transmission. Although there is insuYcient data to determine any additional role which aerosol spread may play this is currently felt to be minor. Papers which suggested aerosol transmission onboard aircraft were flawed by significant movement throughout the cabin and by contact on ground transport and in lounge areas, as well as extended time grounded with the ventilation system switched oV.

TravelRestrictions In the light of these concerns the HPA has examined the evidence on the potential impact of travel restrictions on a possible pandemic. This suggests that imposing an almost immediate 90% restriction on all air travel to the UK when a pandemic is thought to be imminent would delay the peak of a pandemic wave by only one to two weeks. Restrictions limited to travel from South East Asia would be necessarily less eVective as there would be indirect flows of people from Asia into the UK, as well as people infected in outbreaks in other countries. Assuming passengers were screened before travel for clinical symptoms (in countries where there were known to be clusters of cases) there is no additional advantage in entry screening. Even if successful in preventing all those with clinical symptoms from travelling this is only likely to delay the spread of disease by one to two weeks.

SuggestedAreas ofResearch 1. Definitive new studies are needed which will help to illuminate the scientific uncertainty about modes of transmission of influenza virus. 2. Although notification of ill passengers is a tried system for individual passengers it has not been tested in the context of an evolving pandemic when multiple ill passengers might be expected. A live operational field exercise with the aim of testing reception arrangements for an aircraft with symptomatic passengers returning from an aVected area of the world would be beneficial. The aim would be to validate draft emergency plans and identify appropriate staV training. 18 June 2007

Memorandum by ICE (Ideal Cabin Environment) Project ICE (Ideal Cabin Environment) is a multi-nation multi-partner European project addressing the widespread concerns about the impact of aircraft cabin environment on the health and well-being of passengers in commercial planes. Changing passenger demographics, the advent of ultra-long-haul services, and specific health issues such as deep vein thrombosis, have all combined to increase concerns. The ICE consortium, consisting of 15 organisations in eight European countries has the objective to determine, over a three-year project lifetime, the health-based optimum levels and synergistic eVects of aeroplane cabin environmental parameters, including cabin pressure, on the full spectrum of the travelling public. ICE is now halfway through its three-year project period and during this time we have completed a campaign of tests on about 1,500 passengers representing a broad spectrum of the travelling public—including groups with relevant health concerns (respiratory and cardiovascular). We carried out these tests in two specialised aircraft cabin environment test facilities: the ACE (Aircraft Cabin Environment) located at the Building Research Establishment (BRE) in Garston, Watford, UK; and the other at FTF (Flight Test Facility) at IBP in Holzkirchen, Munich, Germany. During these tests we have measured both physiological and psychological responses to diVerent conditions of cabin pressure, temperature, relative humidity, ventilation rate and noise. We will soon be analysing the data with a view to developing a European pre-Standard and providing stakeholders with targeted guidance. ICE is being carried out under the European Commission Sixth Framework Programme and is part-funded by the Commission. BRE in the UK co-ordinates the project and the other partners within the ICE consortium are: — Airbus Deutschland GmbH (Germany); — Antanas Gustatis Aviation Institute of Vilnius (Lithuania); 3844421026 Page Type [E] 30-11-07 13:08:37 Pag Table: LOENEW PPSysB Unit: PAG4

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— Avitronics Research (Greece); — Civil Aviation Authority Aviation Health Unit (UK) who also provides the Medical Chair for the project; — Deutsches Zentrum fur Luft-und Raumfahrt e.V (Germany); — EADS Deutschland GmbH Corporate Research Centre (Germany); — Institute of Building Physics (IBP)—Fraunhofer-Gesellschaft zur Forderung der angewandten Forschuhng e.V (Germany); — Medical University of Vienna (Austria); — Stichting National Lucht en Ruimtevaartlaboratorium (The Netherlands); — Streit (Germany); — Royal Free and University College Medical School (UK); — Universita’ Delgi studi di Padova (Italy); — Carl-von-Ossietzky Universitat Oldenburg (Germany); — Czech Technical University in Prague (Czech Republic). Public domain information on ICE is posted at the website http://www.ice-project.eu/. 19 June 2007

Letter from Dr G A Jamal, MB ChB MD PhD FRCP

CabinAirSafety I am submitting this on a personal basis. My qualifications are MB ChB MD PhD FRCP. I am a consultant physician with specialisation in the field of clinical neurophysiology and I have a special interest in the neurological and neurophysiological assessment of the eVects of neurotoxic factors on the peripheral and central nervous system. I have published extensively on the eVect of organophosphate compounds on human health. Within the last few years I have seen many pilots, co-pilots and cabin crew members as well as passengers who have had episodes of exposure to fume incidents. I have run extensive neurological and clinical neurophysiological assessment on them. Aircrews have presented for testing some time after advising of exposures to aircraft contaminated air, specifically oil lubricant exposure containing organophosphates and a mixture of hydrocarbons. Given that the toxic substances involved in air fume contamination events have high aYnity to lipid material and given that the bulk of the nervous system both peripheral and central is phospholipids, the nervous system is one of the prime toxic targets and is one of the most seriously aVected systems in the body both in the short term and in the longer term. I found that the most commonly encountered manifestations include confusion, drowsiness, fogginess in the head, excessive tiredness, loss of balance and co-ordination, dizziness, clumsiness, headaches, pins and needles and numbness sensation in the extremities, generalised pain and aches. Other common manifestations include diYculty with concentration and short term memory, mood changes, disturbances of sleep and diYculty in finding words. There may be development of intolerance to alcohol and increased sensitivity to a number of chemicals. Other common manifestations include visual blurring, tinnitus, sweating disturbances, bloating, nausea, loss of sexual drive and frequency of micturition. We have investigated these cases systematically and thoroughly with tests looking at the function of the peripheral and central nervous system and the autonomic nervous system. The tests undertaken include EMG and Nerve Conduction Studies, Quantitative Sensory Tests (large fibre VPT and small fibre TTT), Single Fibre Jitter measurement, Multimodality Evoked Potentials (VEP, BAEP & SEP), Cognitive Evoked Potential (CEP & P300) and EEG. Other useful investigations include Neuropsychometric Tests and Autonomic Nervous System Tests. We have aspired to do Brain Functional Imaging (PET & SPECT Scan) but have not done so purely because of cost issues. We have found evidence of abnormalities in this group of patients to variable degrees including peripheral neuropathy particularly small fibre neuropathy and other central abnormalities as well as evidence of dysautonomia with a particular pattern. The findings seen are similar to those found in cases of exposure to organophosphate esters and solvents. Accurate diagnosis is essential not only to characterise the ailment but also to instigate eVective management. 18 June 2007 3844421028 Page Type [O] 30-11-07 13:08:37 Pag Table: LOENEW PPSysB Unit: PAG4

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Letter from Dr Peter Julu, Specialist Autonomic Neurophysiologist and Consultant Physician

EarlyEvidence ofSpecificAutonomicNeuropathy inAircrews I have carried out target-organ specific examination of the autonomic nervous system in a group of aircrews (n% 9) who developed chronic neurological symptoms during the course of their duties and compared the outcomes with a group of coal miners (n% 6) who also became ill following exposure to carbon monoxide due to ventilation accidents, in order to establish the pattern of autonomic dysfunctions in the two groups. The neurological sequelae I found in miners exposed to carbon monoxide and aircrews complaining of ill health consist of a patchy pattern of dysfunctions of the autonomic target organs in various parts of body but mainly in the skin, in the large blood vessels including the heart and in the brain. These neurological sequelae can explain the symptoms and ill health in these two groups of patients. Cholinergic functions are selectively preserved while monoaminergic functions deteriorate in the brain and in the skin among the aircrews. The imbalance between cholinergic and monoaminergic functions in the brain can explain cognitive dysfunction and impairment of short-term memory. The pattern of autonomic dysfunctions in the aircrews is distinctively diVerent from that in miners exposed to carbon monoxide. I am continuing to see more aircrews in my clinics and the pattern of autonomic dysfunctions in these patients is consistent. This is a compelling reason for further investigation, first to confirm the findings in the aircrews by examining a larger number and then to investigate possible common toxic agents among sheep farmers and aircrews. This is so because the pattern of autonomic dysfunctions in sheep farmers and the aircrews is identical. 17 June 2007

Letter from Captain Susan Michaelis My name is Susan Michaelis and I am a former Australian airline pilot with over 5,000 hours flying experience and had my medical certificate failed by the Australian CASA in 1999 after becoming unwell and no longer able to fly in 1997. This occurred after CASA reviewed my medical reports showing that I was no longer fit to fly. While flying from 1987 on various aircraft with no health concerns whatsoever, I then spent almost three years up until mid 1997 flying on the BAe 146 and experienced repeated short term symptoms extremely regularly when in the air conditioned air of the BAe 146. This pattern of smelling fumes on the BAe 146 when the air supply was on, occurred on most flights and I experienced adverse symptoms in flight on most occasions which varied throughout the flight. It was clear that the symptoms were related to oil contamination as they occurred soon after turning the air supply on, which was my job or when in the aircraft with the air on. Additionally the engineers would advise us and all crew knew that it was “just oil” and they were aware of it. 13 years since commencing flying on the BAe 146 and 10 years since having to stop flying, my health has not recovered. The pattern of chronic health eVects that I still experience 10 years later covers many areas and I think I most likely have done more testing than most people in the world to determine what the problems are. A number of the problems I am now left with include but are not limited to: — Respiratory: injury to small airways in lungs causing abnormal respiratory symptomology; — Neurological: abnormal—brain scans, neuronal and glial autoantibodies and neurological assessment; — Neuropsychological: abnormal psychometric and neuropsychological findings; — Autonomic nervous system abnormalities; — Abnormal pathology testing including Biolab (UK) blood tests showing beryllium adducted to my DNA (beryllium is in oil seal bearings), low ATP, increased free cell DNA, reduced superoxide dismutase; — Chronic fatigue; — Chemical sensitivity; — Toxic encephalopathy; — A strong history with an occupational association. These findings have been clearly linked by experts to my repeated exposure on the BAe 146 aircraft and I have a very extensive number of medical reports from senior doctors and scientists from around the world. I am well aware of many other pilots and flight attendants in Australia experiencing almost identical eVects and similarly no longer able to fly in most cases. I am also aware of the same eVects being experienced by many pilots and flight attendants from the UK, USA and other countries. The pattern is remarkable yet the airline and aviation industry denial is ongoing and ridiculous. 3844421029 Page Type [E] 30-11-07 13:08:37 Pag Table: LOENEW PPSysB Unit: PAG4

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70 Please note that I am only referring to aircraft air contamination in this submission which in less than six pages is not possible to summarise 10 years of research. The House of Lords report in 2000 was factually flawed and the errors contained are discussed in the reference manual I have recently published. Therefore I will not dwell on the past and advise some of the new data to have emerged in the last seven years and some data which you seemed unaware of or misinformed on in 2000. Some of the main problem areas are, but not limited to:

Air Quality Sampling Studies to measure the air have never been undertaken during contaminated air events as acknowledged in the Lords to the Countess of Mar: “The Countess of Mar asked Her Majesty’s Government: Further to the Written Answer by the Lord Davies of Oldham on 19 October (WA 126), how many air quality monitoring exercises were carried out during contaminated air events in commercial jet aircraft; and on what occasions. [HL2312] Lord Davies of Oldham: There is no requirement for air quality monitoring exercises to be carried out during contaminated air events in aircraft, and there is no record of any such measurements in the public domain. Air quality measurements are normally only made as part of the initial certification of each aircraft type.” 1 December 2005 Despite this the airline industry continually attempts to use air sampling in normal flights to claim the air during a contaminated air event is safe.

Tricresyl Phosphate (TCP) TCP which is used by most commercial jet engine oils as an anti-wear additive has been identified in all swab samples of UK registered aircraft walls in the last few years, both in the passenger cabin, cockpit and in HEPA filters. TCP is also being found on most tests carried out on Australian, Canadian and US aircraft. TCP has been found in pilots’ blood test, on pilots’ trousers and therefore we know with scientific certainty exposure to TCP is occuring. TCP is a known neurotoxin and I am certain that exposure to travelling passengers and pregnant mothers will certainly not be good news. A blood test to confirm TCP exposure and time of exposure is being funded by many interested parties and will be available later this year. The toxicity of the chemical mixture of contaminants in the oils and hydraulic fluids is misrepresented. The eVects of chronic neurotoxic eVects of TCP exposure is ignored and the general toxicity of TCP is misused.

2007 UK BAe 146 Research and BAe alleged payments Initial analysis of the survey data shows that of 359 past and present UK based known BAe 146 qualified pilots, 242 were contacted and responded to the survey request in the form of telephone or written responses to a two year survey looking at exposure history to contaminated air and any eVects experienced. 138 (57%) pilots of the 242 respondents reported adverse eVects ranging from short through to long term eVects (one deceased). Of these 82 (34%) reported short term adverse eVects only, while 61 (25%) advised medium to long term symptoms, most likely in addition to short term eVects. 207 (86%) pilots advised that they had been exposed to contaminated air on the BAe 146 with only 8% advising they had not been exposed to such air. 18 pilots (7.4%) advised that they had had their medical certificates withdrawn by the CAA or had taken early medical retirement with a range of health eVects and exposure background. Several other pilots reported having to take between several months to a year oV work to recover from adverse eVects. The data presented clearly identifies serious trends that support previous studies and shows a full scale epidemiological survey is urgently required of all crews who flew the BAe 146 as pilots or cabin crew. Lord Tyler asked the following question in the House of Lords which received a brush oV answer and which surely should be investigated by a Royal Commission: 9 Oct 2006 : Column WA13 Aviation: Contaminated Air “Lord Tyler asked Her Majesty’s Government: Whether they are aware of any payments made by British Aerospace Regional Aircraft Limited to Ansett Transport Industries Operations Limited and East West Airline Operations Limited, under an agreement dated 3 September 1993, in connection

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with design flaws in the BAe 146 aircraft allowing contamination of cabin air by oil and other fumes; and, in light of that agreement, what steps they took at that time to ensure that regulations pertaining to cabin air quality were enforced.[HL7230].”

Medical effects and the BALPA Conference 71 The 2000 Lords report failed to highlight the wealth of data confirming ill eVects in crews and passengers exposed which has existed for over 30 years. Crews around the world are showing a remarkable similarity in symptoms experienced. The health eVects being reported and diagnosed by medical doctors and other experts show a very strong pattern and are supported by physical evidence. Medical eVects being seen in crews include but are not limited to: respiratory damage, CNS and PNS problems, autonomic nervous system and neurological damage, neuropsychological eVects, immune system eVects, reproductive problems, genetic problems, fatigue and many more.72,73 Reports of Parkinson’s, MS, ME were also being reported74 by crews and their doctors all with strong history of exposure to contaminated air. These are all discussed in detail in the Aviation Contaminated Air Reference Manual and other published papers referenced therein. Since 2000 numerous published papers, and a 2005 Contaminated Air Conference in London have confirmed that crews and passengers are suVering both short and long term medical eVects of exposure to contaminated air in aircraft. Only the airline industry and those who attempt to protect them remain in denial. The 2005 contaminated air conference organised by BALPA made the following conclusions: — “There is a workplace problem resulting in chronic and acute illness amongst flight crew (both pilots and cabin crew); — The workplace in which these illnesses are being induced is the aircraft cabin environment; — This is the resulting in significant flight safety issues, in addition to unacceptable flight crew personnel health implications; — Further, we are concerned the passengers may also be suVering from similar symptoms to those exhibited by flight crew.” 75,76 There is now a confirmed report of MND from a pilot with a strong history of exposure. Increased MND levels has previously been noted in aircrew. Likewise there are papers linking Parkinson’s to hydrocarbon exposure and a misdiagnosis of MS to TCP exposure. These are all listed in chapter 7 of the Aviation Contaminated Air Reference Manual. The oil warning labels and MSDS sheets have at various times listed nervous system eVects as one of the outcomes of repeated inhalation of the oils. Workers compensation cases have been won in Australia, USA and Canada since 2000 where medical eVects of exposure have been accepted as real and genuine

SwedishData Following a serious event on a BAe 146 aircraft in Sweden, both pilots were incapacitated for about five minutes in flight, the chemical combination they were exposed to, has recently become available. This data clearly shows that the synergistic eVects of exposure to pyrolised jet engine oils, is a serious health and flight safety hazard. The airline industry continues to misinform passengers and crews that air quality testing has shown nothing as all levels found were low. In fact no testing in flight during a contaminated air event has ever been published and it is the cocktail of chemicals once heated that clearly had the eVect of incapacitation of both pilots in flight for a period of five minutes during a descent at night. It was only oxygen that enabled the pilots to land the plane. This data is available for review. TCP was found amongst the mixture of contaminants as was CO. Clearly looking at individual levels of chemicals is a pointless and misinformation exercise. Additionally it is well accepted by even many within the aviation industry that exposure standards cannot be applied to an aviation setting. Therefore to say all levels are low is pure misinformation.

71 Lubricating Oil. Clinical Toxicology 1977; 11: 423–426. 72 Montgomery,Quality In Airplane M R, Cabins Wier, G And T, Similar Zieve, F Enclosed J, Anders, Spaces— M WThe Human Handbook Intoxication of Environmental Following Chemistry Inhalation—Publisher: Exposure toSpringer-Verlag Synthetic Jet Gmbh. August 2005. 73 Winder, C, Michaelis, S, (2005). Aircraft Air Quality Malfunction Incidents: Crew EVects from Toxic Exposures on Aircraft. Air In-Cabin Airborne Contaminants. Journal Of Occupational Health and Safety—Australia And New Zealand 18: 321–338, 2002. 74 Winder,South Wales, C, Fonteyn, Sydney P, NSW Balouet, 2052, J Australia,"C. (2002) August Aerotoxic 2005. Syndrome: ISBN: 0-7334-2282-9. A Descriptive Epidemiological Survey Of Aircrew Exposed To 75 ContaminatedMedicine, Volume Air 40(11) Protection: November Proceedings 1998 p of 980–985. the Air. Editor: Chris Winder. Publisher: School of Safety Science, University of New 76 Nicholas, J S, Lackland, D T et al “Mortality among US commercial pilots and navigators” Journal of Occupational and Environmental

Nicholas J S, Butler G C, Lackland D T et al (2001) Health among commercial airline pilots. Aviat Space Environ Med: 72:821–6. 3844421029 Page Type [E] 30-11-07 13:08:37 Pag Table: LOENEW PPSysB Unit: PAG4

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Failure of theRegulatoryProcess The aviation industry and governments globally are systematically downplaying the significance of the data available showing the extent of the problem of cabin air contamination. The UK Government, the CAA, the AHWG are particularly at fault here. The reason most likely is that the CAA is fully funded by the industry that it regulates and therefore clearly protective of the aviation industry, particularly British Aerospace. Especially as aviation is about a third of all UK exports. The CAA, EASA and other regulators are ignoring the aviation regulations that exist that if adhered to would partly protect the public and crew from air contamination. Contaminated air is of course a flight safety concern in all cases as shown in the regulations. Impaired crew performance (very common) to any degree is a flight safety risk and cannot be dismissed as it has been by the CAA and many others. The data shown in the Aviation Contaminated Air Reference Manual reviewing the 1050 contaminated air events shows that 32% of events involved some degree of crew impairment. It must be remembered that the evidence shows that most events are never reported in the first place and the reporting system does not advise crews to report health eVects or adverse symptoms.

OPICN The 2000 Lords report mentions the medical eVect of exposure to Tricresyl Phosphate known as OPIDN but failed to look at other conditions such as OPICN (chronic neurotoxicity) now being seen as a serious concern. Additionally blood testing of crews, by way of autoantibody tests at Duke University in the USA, is showing serious and concerning problems.

COT Investigation The UK Committee on Toxicology (COT) is not looking at the data provided appropriately at all and its industry bias is extremely apparent to those who understand this issue. To suggest it is independent is nonsense. The COT investigation into air quality appears to be like in previous investigations they have carried out failing the public for corporate profit. The Committee has refused to listen to crew and most of the concerns from medical experts who have seen the crews and investigated this issue. In fact it is almost a foregone conclusion that the COT will either dismiss the whole issue or more likely as advised in the last meeting, find that there is no correlation between exposure events and crew illness (more research needed) as measuring has not taken place. This is pure misinformation as the data in the Swedish section above clearly shows in a known oil leakage event what the outcome of exposure to a mixture of substances in the oil can be, and there is a vast amount of evidence showing crew eVects are more likely than not strongly related to the contaminated air. However, the COT is virtually ignoring all of this or misusing the significance of the data provided to it. Most crew data will have never even been reviewed by the COT as they have shown such strong industry bias towards this issue.

Under Reporting The frequency of oil leaks and contaminated air is not rare at all and the data available shows that such events are not uncommon, are mostly never reported and are seen as “normal” or a mere “nuisance” and therefore not worthy of reporting. The CAA deliberately77,78 does nothing to correct this situation and in fact denies it is occuring despite clear and published evidence that this is the case. Admissions that the reporting system is not working comes from within the aviation industry itself. Under reporting of contaminated air events continues with less than 4% actually reported. This results in the industry failing to address the matter. All contaminated air events should be reported as per legislation worldwide. Regrettably regulators, especially the UK CAA, fail to enforce their own regulations. To do so would be too costly to the airline industry. I am aware that a number of British airlines are privately advising their pilots that contaminated air events, unless they are major events, are not required to be reported to the CAA. No matter what the airlines advise the COT or CAA, there is evidence to show that crews are being told that contaminated air events which the airline does not consider significant are to be reported internally only or not at all. Even the CAA and UK Government via answers in Parliament support this view in various statements made.

77 and New Zealand 19: 253–261, 2003. 78 Michaelis,Edinburgh, S, SA, (2003), 2004. A survey of health symptoms in BALPA Boeing 757 pilots, Journal of Occupational Health and Safety, Australia Dr Bhupi Singh (2004) Australia Aviation Safety Spotlight 0304: In flight smoke and fumes. Senior Research OYcer, AVMED, RAAF 3844421029 Page Type [O] 30-11-07 13:08:37 Pag Table: LOENEW PPSysB Unit: PAG4

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Filters Filtration technology to filter the bleed air exists today, in fact some units remain on shelves collecting dust as the airline industry has yet to take steps to protect the travelling public. Filters could prevent exposures on aircraft in current aircraft. In the future all aircraft should be bleed-free as the Boeing 787 is. If the Committee feels that having bleed free aircraft would minimise the risk of contaminated air as it does it should consider making this important point so that other aircraft manufacturers follow the route chosen by Boeing.

Passengers Passengers are owed a duty of care to be informed of the potential problem of contaminated air, when they are exposed and oVered medical help by Independent medical bodies after exposures. None of these human rights are currently being actioned by the airline industry. The Government should stop protecting the industry and look after the people’s needs and rights. I am entitled to make strong statements with regard to aircraft air contamination issues as I have researched this issue for 10 years now, and am in contact with hundreds of crews and crew groups from around the67 world. I have published numerous papers on the issue and have been involved in much of the research. I have very recently published much of the known information in what is a collated source that is being seen as the authoritative guide on this issue and the only combined source comprehensively covering the issue. It is a collaborative and extremely comprehensive review of the subject matter. It was at the 2005 BALPA Contaminated Air Conference that the General Secretary of BALPA advised that he was not only concerned about the eVects being seen in crews and those possible for passengers or the unborn, but was also concerned that real action was required. He was concerned that the issue should not be passsed to a government department or transport committee which would bring the issue to a halt. This is precisely eVectively what has happened by the transparent actions of the UK DfT, CAA, AHWG and the COT. There certainly are solutions available both in terms of the contamination issue as well as the medical research that ought to take place. However, such positive actions can only be taken by those who are willing to recognise what has gone on and enact change. One such step on the medical front includes a major research program that could be undertaken Professor Robert Haley who has been awarded funding by the US Congress to undertake furhter brain imaging techniques in conjunction with a full scale epidemiological survey and other investigations. We have been advised this should and could be undertaken in relation to the aircraft contaminated air issue, yet to date there has not been the will to make this happen. 79,80 May I close by hoping that this new investigation does not result in similar comments to those expressed by the Chairman of the very comprehensive Australian Senate Inquiry, who was not at all impressed with the House of Lords inquiry. “I met with the woman who was the Chair of the House of Lords Inquiry, Baroness Wilcox and she admitted to me over lunch that she felt she was being “snowed” by the bureaucrats on her Committee but felt there was nothing she could do about it. I urged her to examine the evidence independently and write her own report. But quite clearly the House of Lords Inquiry again, the report was pretty much a “cover up” of the evidence which that inquiry was given; She felt she was being “conned” by the bureaucrats and, having read the House of Lord’s Report, I believe she was!” 17 June 2006

Memorandum by NYCO The attention of our company has been recently drawn onto an incorrect statement in the 2000 report of the House of Lords Select Committee on Science and Technology Air Travel and Health. The paragraphs 4.35 to 4.41 refer to potential poisoning by components included into the jet engine oil, of which tri-cresyl-phosphate (TCP). This field of jet engine oil formulation is very well known to NYCO SA as a corporation, because we have been designing, manufacturing and marketing such products since 1959.

79 80 UNSW. Proceedings of the BALPA Contaminated Air Protection Air Safety and Cabin Air Quality International Aero Industry AOPISConference, DVD: held “Contaminated at Imperial College, Air: An London, ongoing 20–21 Health April and2005: Safety ISBN issue” 0-7334-2282-9. Comment by Reverend J Woodley. Woodley Reverend J, The Politics Of Aircraft Health And Safety Senate Inquiry, Australian Parliament October 2000. BALPA, 3844421030 Page Type [E] 30-11-07 13:08:37 Pag Table: LOENEW PPSysB Unit: PAG4

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Paragraph 4.36 states that “Mr Fogarty of Exxon-Mobil commented that no other additive had been found to match TCP’s anti-wear and load-carrying performance”. This is not accurate as NYCO SA has been marketing since 1985 a jet engine oil, “Turbonycoil 600”, that does not include any TCP in its formulation, albeit containing an additive of the same family. In spite of the absence of TCP, Turbonycoil 600 meets all the technical requirements of the engine manufacturers and military authorities in charge of the approval of such products.

In particular, it is duly approved to the MIL-PRF-23699 specification,81 which is the ruling specification for all today’s commercial engine oils. Turbonycoil 600 is also approved for over 40 diVerent commercial and military engines manufactured by the Rolls-Royce, General Electric, Pratt & Whitney and Snecma, including the very popular commercial engines CFM56, V2500 and RB211. The considerable flight experience accumulated since 1985 on gas turbine engines is a clear evidence that the use of TCP in jet engine oils can be avoided, without compromising at all the quality and performance of the oil in the engine. Turbonycoil 600 is in particular the oil currently used by the Royal Air Force and Royal Navy under the Ministry of Defence designation “OX-27”. Paris 12 June 2007

Letter from Mr Ian Panton

AirTravel andHealth

1. I am writing in response to the call for evidence on the health eVects of air travel, with particular emphasis on any relevant new evidence that has emerged since 2000, and on the extent to which Government, regulators and the airline industry have kept pace with such evidence. 2. I would specifically address recommendations 1.43 (c), (d) and (e) in the 2000 Report on Air Travel and Health.

3. In June 2005 I forwarded a letter, to Dr Ruge at the CAA expressing my concerns about contamination of82 the breathing air supply to the pressure cabin. Dr Ruge confirmed that the “results (of83 UK Government and CAA initiated and sponsored research into cabin air quality)” which “did not suggest that there is a health risk for passengers, including infants, or crew” were contained in84 the paper Cabin Air, published in 2004, and that “Other research has been carried out and can be found on the DH website”. 4. Looking first at: CAA Paper 2004/04 Title: Cabin Air Quality, I found that: “The research described in this report addresses the eVect of cabin air contamination on the pilot’s ability to safely fly and land the aircraft. The CAA decided to conduct this research following a small number of events where flight crew eVectiveness was reduced, possibly due to oil products present in cabin air. Although some references are made concerning long term health eVects, the scope of this research did not include an attempt to determine the extent of any such risk.” 5. So, with reference to health eVects, especially to passengers, and certainly infants, this paper appeared irrelevant. However, this paper did provide, at Appendix A to Chapter85 2 (page 14), a graphic illustration of contamination found within a breathing air duct. 86 6. Moving onto the other research; the overview from the DfT led to the main document: Client Report: Extending CabinAir measurements to include older aircraft types utilised in high volume short haul operation Client report number 212034. 7. Whilst the work was informative I could not find any reference to the diversity, including infants, of passengers carried. Accordingly I again asked Dr Ruge for any further “UK Government and CAA initiated and sponsored research into cabin air quality” that do not “suggest that there is a health risk for passengers, including infants, or crew”. I received no further information.

81 82 83 84 For further information, please refer to our website: http://www.nyco-lubricants.com 85 http://www.caa.co.uk/application.aspx?categoryid%33&pagetype%90&applicationid%11&mode%detail&id%1250 86 http://www.dft.gov.uk/stellent/groups/dft control/documents/contentserverteplate/dft index.hcst?n% 9778&l%3 http://www.caa.co.uk/docs/33/CAPAP2004 04.PDF http://www.dft.gov.uk/stellent/groups/dft aviation/documents/page/dft aviation —027561.hcsp http://www.dft.gov.uk/stellent/groups/dft aviation/documents/page/dft aviation —027562.pdf 3844421031 Page Type [O] 30-11-07 13:08:37 Pag Table: LOENEW PPSysB Unit: PAG4

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8. On 8 December 2005 (Hansard, House of Lords, Column GC133) The Countess of Mar stated: “Despite the two key recommendations of the Select Committee identified by the AHWG to the Building Research Establishment for its client report, extending cabin air measurements to include older aircraft types utilised in high volume short haul operation, of October 2003, there is still no regular monitoring of cabin air quality. The recommendations stated: “We recommend that airlines collect, record and use at least some of the basic cabin environment data being continuously monitored, not only to give authoritative substance to their refutation of the common allegations, but also to provide a better basis for public confidence in these matters. Indeed we are surprised that they do not already do so . . . We recommend airlines to carry out simple and inexpensive cabin atmosphere sampling programmes from time to time, and to make provision for spot sample collection in the case of unusual circumstances. This would be helpful to passengers and staV and also benefit the airlines themselves.” Recent Written Answers given by the Minister to my questions have elicited the fact that there is no monitoring and no filtration on aeroplanes. The only time that an aircraft is monitored is when it is commissioned. That is a horrendous thought. Why, five years after the Select Committee made those simple, inexpensive recommendations, has nothing been done to implement them? I am told that an eYcient filtering system costs a few thousand pounds—peanuts when compared with the cost of an aircraft, the cost of sick leave for a crew or, worse still, the loss of an aeroplane full of passengers. 9. On 8 March 2006 (Hansard Column 812), in response to Lord Davies of Oldham, the Countess said: “My Lords, the Minister called in aid the House of Lords Science and Technology Select Committee report. Need I remind him that it did not say that there was no problem over contaminated air and that it recommended that air quality in cabins and cockpits should be regularly monitored? It is now six years later and no such monitoring has taken place.” 87 10. As to new evidence there was a paper published in 2005 The eVect of high altitude commercial air travel on oxygen saturation, and in 2006 Activation of coagulation system during air travel: a crossover study.” The latter is quite important since the role of cabin altitude on oxygen in blood content is beginning to be known for a general population. However, the relation of blood oxygen content and air pressure to Indoor Air Quality (IAQ) contaminant health eVects is, I believe, unknown. 11. I remain concerned that: — Some of the recommendations of the House of Lords Science and Technology Select Committee have not been implemented; — Given there is no filtration nor monitoring of the breathing air supply to the pressure cabin it is surely impossible to ensure that this life critical supply is maintained, all stages of transit, at an optimum level? 12. Perhaps the way forward lies with the Boeing 787 (Dreamliner) which, I am given to understand, will not use a bleed air supply for the pressure cabin. 17 June 2007

Memorandum by the Research Institute for Sport and Exercise Sciences, Liverpool John Moores University 1. Progress in research into the priority areas identified by the Committee in 2000: Our research at Liverpool John Moores University (Research Institute for Sport and Exercise Sciences) has focused on: — the phenonmenon of jet lag, and methods of accelerating adjustment of the body clock to the new time zone; and — factors aVecting choice of foods and subjective responses to food served on board long-haul flights. 2. A list of publications is appended. In a number of these publications, the House of Lords report has been referenced, as it provided the stimulus for some of this research work. 3. Progress made by the airline industry and information supplied to travellers: — There have been small but perceptible improvements in attention to travellers. Water is oVered more systematically on long-haul flights. In-flight entertainment is individualised to provide a more comfortable flight experience. Ear plugs are provided to all passengers by the major carriers. There

87

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is little change in the space available to individual passengers and it seems that a cramped posture is more or less accepted as a corollary of travelling, especially for those in higher percentile anthropometric groups. Pre-flight advice about seating space is not usually provided; — Information on coping with jet-lag and preventing deep-vein thrombosis is not overtly provided. Flight magazines may contain illustrations of recommended exercises but these are not suYciently promoted to be taken up by passengers. What is needed is advice similar to that provided for safety, after boarding or at check-in (there are more fatalities from deep-vein thrombosis than from emergencies); — The airport environment has been the subject of a recent initiative of the American College of Sports Medicince. A symposium on “jet stress” at its Annual Conference (2007) considered how to promote health-related behaviour among travellers eg walking around the airport rather than snacking. A Working Group of the College is active in this project but its impact on lifestyle changes is likely to be marginal, if at all, and has questionable acute consequence for travellers; — The phenomenon of jet-lag and the risk of deep-vein thromboses are now unequivocally accepted by the airline industry. This was not so prior to 2000.

4. Areas we have covered, 2000–current: — We have continued to write articles concerned with circadian rhythms in general, part of which is travel; — Specific reviews on travel, dealing with travel fatigue and jet lag have been written. These have also attempted to oVer advice to the general traveller, to athletes and to aircrew. There is also a web site that gives information and advice on light and melatonin; — We have not dealt specifically about the cabin environment, but this is covered in many of the reviews (part of travel fatigue). In addition, we have considered the palatability of food in trans-meridian travellers; — We have produced several pieces of evidence relating to what, exactly, is meant by “jet lag”; — We have produced a review of the eVects of noise upon sleep in those living near to a major international airport; — We have considered the “problem” of melatonin; whether or not it is eVective (in many of the reviews), problems associated with its use, and the lack of information relating to its toxicology, particularly in the long-term; — We have also attempted to produce simple, non-intrusive methods for establishing sleep loss and altered activity patterns after flights. 8 June 2007

Publications

General Reviews on Circadian Rhythms, including Travel

Waterhouse, J, Minors, D, Waterhouse, M, Reilly, T and Atkinson, G (2002). Keeping in Step with your Body Clock. OUP, Oxford. J Waterhouse and P DeCoursey (2004). The relevance of circadian rhythms for human welfare. In Chronobiology. Biological Timekeeping (eds J Dunlap, J Loros, and P DeCoursey). Sunderland, MA: Sinauer, pp 325–356. Reilly, T and Waterhouse, J (2004). Sport, Exercise and Environmental Physiology, Elsevier, Edinburgh. 3844421032 Page Type [O] 30-11-07 13:08:37 Pag Table: LOENEW PPSysB Unit: PAG4

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Reviews on Travel and Jet Lag T Reilly, G Atkinson, J Waterhouse (2000). Chronobiology and physical performance. In: Exercise and Sport Science (eds) W Garrett, D Kirkendall, Lippincott Williams, Philadelphia, pp 351–372. J Waterhouse (2000). Brief review: jet lag. Travel Wise 6: 5–6. Reilly, G, Atkinson, J, Waterhouse (2000). Endurance performers and time-zone shifts. In: Endurance in Sport, 2nd Edition, (ed) R Shephard and P Astrand, Blackwell Science, Oxford, pp 639–650. Waterhouse, J, Edwards, B, Carvalho Bos, S, Buckley, P and Reilly, T, (2002), Circadian rhythms and some aspects of jet lag and shift work, with particular reference to athletes. European Journal of Sport Science, 2(6): 19 pages. J Waterhouse, T Reilly, B Edwards (2003). Long-haul flights, travel fatigue and jet lag. In: Passenger Behaviour (ed R Bor), Ashgate Publishing Ltd, Aldershot, UK, pp 246–260. J Waterhouse, D Minors (2003). Circadian rhythm Abnormalities. In: P Redfern, ed Chronotherapeutics. London: Pharmaceutical Press. pp 309–341. Reilly, T, Edwards, B J and Waterhouse, J, (2004). Long-haul travel and jet-lag: Behavioural and pharmacological approaches. Medicina Sportiva, 7: E115–E122. J Waterhouse, T Reilly, B Edwards (2004). The stress of travel. J Sport Sci., 22: 946–966. Reilly, T, Edwards, B, Waterhouse, J and Atkinson, G, (2005). Jet lag and air travel: implications for performance. Clinics in Sports Med. 24: 367–380. Waterhouse J, Spencer M, Elsey A, Edwards B, Atkinson G, Reilly t (2006). Occupational factors in pilot mental health: sleep loss, jet lag, and shift work. In: Aviation Mental Health ed R Bor, T Hubbard, Ashgate Publishing, Aldershot, pp 255–284. Waterhouse, J, Reilly, T, Atkinson, G, Edwards, B, (2007). Jet lag: trends and coping strategies. The Lancet, 369, 1117–1129. Reilly, T, Atkinson, G, Edwards, B, Waterhouse, J, Akerstedt, T, Davenne, D, Lemmer, B, Wirz-Justice, A, 2007. Position Statement. Coping with jet-lag: A position statement for the European College of Sport Science. Eur J Sport Sci, 7:1–7. A web site (in collaboration with Medical Advisory Service for Travellers Abroad) on jetlag:http:// www.masta-travel-health.com/travel-health-library.aspx?page group%15£p

Jet Lag J Waterhouse, B Edwards, A Nevill, G Atkinson, T Reilly, P Davies, R Godfrey (2000). Do subjective symptoms predict our perception of jet lag? Ergonomics 43: 1514–1527. Waterhouse, J, Edwards, B, Nevill, A, Carvalho, S, Atkinson, G, Buckley, P, Reilly, T, Godfrey, R and Ramsay, R, (2002). Identifying some determinants of “jet lag” and its symptoms: a study of athletes and other travellers. Br J Sports Med, 36: 54–60. J Waterhouse, A Nevill, B Edwards, R Godfrey and T Reilly (2003). The relationship between assessments of jet lag and some of its symptoms. Chronobiology International, 20: 1061–1073. Waterhouse, J, Nevill, A, Finnegan, J, Williams, P, Edwards, B, Kao, S, Reilly, T, (2005). Further assessments of the relationship between jet lag and some of its symptoms. Chronobiol Int 22: 107–122. J Waterhouse, S Kao, D Weinert, B Edwards, G Atkinson and T Reilly (2005). Measuring phase shifts in humans following a simulated time-zone transition: agreement between constant routine and purification methods. Chronobiol Int 22: 829–858.

Melatonin B Edwards, G Atkinson, J Waterhouse, T Reilly, R Godfrey, R Budgett (2000). Use of melatonin in recovery from jet-lag following an eastward flight across 10 time zones. Ergonomics 43: 1501–1513. Atkinson, G, Buckley, P, Edwards, B, Reilly, T and Waterhouse, J, (2001). Are there hangover-eVects on physical performance when melatonin is ingested by athletes before nocturnal sleep? Int J Sports Med 2001; 22: 232–234. Herxheimer A and Waterhouse, J (2003) Editorial: The prevention and treatment of jet lag. British Medical Journal 326:296–297. 3844421032 Page Type [E] 30-11-07 13:08:37 Pag Table: LOENEW PPSysB Unit: PAG4

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Activity S Carvalho Bos, J Waterhouse, B Edwards, R Simons, T Reilly (2003). The use of actimetry to assess changes to the rest-activity cycle. Chronobiology International, 20: 1039–1059.

Noise Waterhouse, J, Simons, R, Reilly, T, Valk, P, (2004). Non-Auditory Health EVects of Aircraft Noise with Special Reference to Sleep Disturbance. Report commissioned by Sciphol Airport. Liverpool John Moores University, 56 pp.

Food intake J Waterhouse, S Kao, B Edwards, D Weinert, G Atkinson and T Reilly (2005) Transient changes in the pattern of food intake following a simulated time-zone transition to the east across eight time zones. Chronobiology International, 22: 299–319. Waterhouse, J, Kao, S, Edwards, B, Atkinson, G, Reilly, T, (2006). Factors associated with food intake in passengers on long-haul flights. Chronobiology International, 23: 1–23.24.

Memorandum by Ms Christine Standing MA

Flying in theFace ofScience:HumanFactorsConsiderations in theCabinEnvironment

Executive summary This report gives a brief outline of ICAO’s recommendations to the airlines in all participating States, regarding Human Factors. It refers to cases that fall short of ICAO’s scientifically-based recommendations in the areas of: — Human Factors Management; and — Physical Environment. It demonstrates that, while evidence exists regarding standards that the UK should adopt, we are falling short of that standard. The results are demonstrated in cases (not statistics) of morbidity and mortality. Human Factors as a discipline exists: “To identify why actions lead to the breakdown in defences and result in accidents. This requires determining the related latent failures present at all levels of the organization (including the upper levels of management) and of the aviation system of which it is a part. It goes without saying that it is equally important to determine how these unsafe actions could have been prevented. We cannot prevent humans from making errors, but we can reduce the frequency of these errors and limit their consequences. This is the essence of prevention activities and highlights the importance of investigation and reporting of incidents” (Human Factors Digest No 7. circular 240-AN/144. 1.28). The problem with an accident caused by the events described herein, is that the evidence within the causal chain would be undiscoverable, and therefore have no remedy within the safety system. Ad hoc science is no science; this Report recommends how we may retrieve and apply the necessary standards in Human Factors.

Introduction Since the Science and Technology Select Committee published its report on Air Travel and Health (Fifth Report, Session 1999–2000, HL Paper 121) there have been two major developments regarding pilot mortality and pilot morbidity respectively. These, illustrated here, demonstrate how the system is currently working. The first is reference to a Case Report based on the working conditions of the late Captain Peter Standing QCVSA in the months preceding his sudden death, and the complaints procedure following this. The second addresses an aspect of the question: “To what extent has the aircraft cabin environment improved?” I welcome this opportunity to give evidence on the health eVects of air travel, with particular emphasis on relevant new evidence that has emerged since 2000, and on the extent to which Government, regulators and the airline industry have kept pace with such evidence. This paper will address two areas requested by the Committee. These are: more research into the health eVects of air travel; and changes to Cabin Service 3844421033 Page Type [O] 30-11-07 13:08:37 Pag Table: LOENEW PPSysB Unit: PAG4

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Procedures. A clearer understanding of these areas is dependent on a knowledge of Human Factors in aviation (described very briefly). One objective is to highlight the need for better research and adherence to better procedures following cases of mortality and morbidity among crew.

Human Factors in Aviation

Human Factors is a multi-disciplinary subject that covers medicine, psychology,88 physiology, chronobiology, law, and more. It integrates these as part of a safety system. “The field of Human Factors extends well beyond the physiological and the psychological; ironically, most investigators, unbeknown to themselves, have a broad awareness of the subject which they apply in an informal manner.” This is not to condone an informal approach to safety; there is no room for an ad hoc, informal approach. 89 An accident or incident? These are “not solely the result of an action taken by one individual. The potential for an accident is created when human actions and latent failures present within an organization or the air transport system interact in a manner which breaches all of the defences”. The purpose of investigating human factors: this is, “to identify why actions lead to the breakdown in defences and result in accidents. This requires determining the related latent failures present at all levels of the organisation (including the upper levels of management) and of the aviation system of which it is a part. It goes without saying that it is equally important90 to determine how these unsafe actions could have been prevented. We cannot prevent humans from making errors, but we can reduce the frequency of these errors and limit their consequences. This is the essence of prevention activities and highlights the importance of investigation and reporting of incidents.”

Investigators:“When we seek to91 resolve a legal problem, we go to a qualified lawyer for advice. If we are building a house we employ a qualified architect . . . when it comes to solving human factors problems, we have traditionally been content to handle these using a do-it-yourself approach, even though hundreds of lives may depend on the outcome.” Investigators should be trained professionals, qualified and drawn from the aviation world. However, “Investigators may mishandle questions related to the performance of crew members, air traYc controllers, maintenance personnel and others. This can happen when the investigator92 has not established an atmosphere of objectivity and trust, and those whose performance is being questioned feel threatened by or antagonistic towards the investigator. In the worst case, crew members or other interested parties may withhold valuable information and assistance from the investigation authority.” Solution: “Investigators should ensure that people understand the objective of the process—to prevent recurrence . . . if there is a possibility of misunderstanding, this information should be discussed openly at the beginning of the investigation.” (ibid.) Obstacle: “There is often a natural reluctance on the part of witnesses, for the purposes of this digest these include peers, supervisors, management and spouses, to speak candidly about the deceased.” (ibid.) 93 Human Factors and Well-Being: One component of this discipline addresses “equipment, working arrangements, procedures and environmental control” so that it “can be matched to (people) and thus enhance the overall eVectiveness of the system and the well-being of the individuals concerned.” ICAO Article 38: This relates to “Departures from international standards and procedures. Any State which finds it impracticable to comply in all respects with any such international standard or procedure, or to bring its own regulations or practices into full accord with any international standard or procedure after amendment of the latter, or which deems it necessary to adopt regulations or practices diVering in any particular respect from those established by an international standard, shall give immediate notification to the International Civil Aviation Organization of the diVerences between its own practice and that established by the international standard.” Where amendments to standards are not complied with that State shall94 give notice to the Council within sixty days of the adoption of the amendment. It should “indicate the action which it proposed to take. ICAO would then notify all other states of the diVerence which exists between one or more features of an international standard and the corresponding national practice of that State.”

88 89 90 91 Human Factors Digest No 7. circular 240-AN/144. HumanFoundation. Factors Digest No 7. circular 240-AN/144 para 1.27. 92 Human Factors Digest No 7. circular 240-AN/144. 1.28. 93 Hawkins, Frank H, (Captain) (1989) Educating the Educators in Human Factors. Vol 36.No 2. March/April 1989 Flight Safety Medicine. Vol 36. No 1. January/February 1989 Flight Safety Foundation. 94 Human Factors Digest No 7. circular 240-AN/144.). Hawkins, Frank H, (Captain) (1989) Human Factors and Medicine: Clearing up some Confusion. Human Factors and Aviation

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138 air travel and95 health: evidence

Work-Related Deaths—A Protocol for Liaison: The purpose of the protocol is to ensure eVective liaison between diVerent investigative and prosecuting authorities when there has been a work-related death. It would be essential in all cases of premature pilot mortality, whether or not the actual death took place at the workplace. (a) A work-related death “is a fatality resulting from an incident arising out of, or in connection with, work”; (b) “There will be cases in which it is diYcult to determine whether a death is work-related . . . each fatality must be considered individually, on its particular facts, according to organisational internal guidance, and a decision made as to whether it should be classed as a work-related death”; (c) “In determining the question, the enforcing authorities will hold discussions and agree upon a conclusion without delay; (d) “If a Coroner does not recognise the death as work-related; and if a company is so minded, this first step will be ignored”. Evidence-based practice: The fields of medicine, law, policy-making, nursing (and more) now use evidence- based practice. This is: — transparent; — scientific; — up to date; — systematically reviewed; — peer-reviewed; — trustworthy research. Concluding Remarks: In this section, a brief outline of the subject, Human Factors, has been outlined, mainly by using the International Civil Aviation Digests. The subject is enormous. There can be no understanding of this paper without an awareness that Human Factors is an integrated system, some of which is enshrined in law. There can be no ad hoc approach to safety.

More research into the health effects of air travel

This section describes a case that demonstrates failures in the current practice and research into health eVects of air travel, seen through the Human Factors discipline. The Committee “recommend(ed) airlines to review their systems and procedures for dealing with passenger concerns and complaints so that passengers do not feel that they are being forced to deal with lawyers and insurers from the outset.” (Paragraph 8.60). This review illustrates that there is a case for an independent “ombudsman”. Case: Flight VS29/30 Bridgetown Barbados. Monday 1 April–Friday 5 April 2002. Captain Peter Alfred Standing QCVSA

This Case Study is an account96 of airline management in the UK prior to the sudden death of Captain Standing. This occurred a few days after an “altercation” on the flight deck of a 747, during a longhaul flight. It described the working conditions of the late Captain Peter Standing (QCVSA) in the months preceding his sudden death. It detailed the altercation. 97 The Report supplied evidence in the form of copies of letters from the deceased to the airline. These related events about bullying and unfair practices; citing an Instructor, “I think we owe Standing an apology;98 I think we destroyed him.” Recent research findings had been cited in these letters, one referring to possible deaths from the eVects of99 current practices. Using Evidence-based practice, he cited the HSE itself. This had made the connection between stress and heart disease in “Work related factors and ill-health”. The airline response was brief, “I can’t agree”—a personal response with no scientific evidence or consideration to support this view.

95 96 97 98 Work-Related Deaths. A Protocol for liaison: www.hse.gov.uk/enforce/index.htm Standing,Research Report C (2004) 266/2000,Crown “Civil Aviation; copyright Civil War?” 2000. Report prepared for the Centre for Corporate Accountability. 99 Letter: Command Training (ICUS) 1 October 1996. Stansfield, Stephen, Head, Jenny and Marmot, Michael (2000) The Whitehall II Study. Work related factors and ill health. Contract

Letter from airline to P A Standing. Undated. 3844421033 Page Type [O] 30-11-07 13:08:37 Pag Table: LOENEW PPSysB Unit: PAG4

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Shortly after this flight, Captain Standing drafted a report that he intended to send to the CAA. In it, he outlined what he called “an attack” by a cabin crew member on him. After his death, this was made available to the CAA by his widow (a passenger on the plane), primarily in order to prevent further erosion of the safety system, and also as a complaint.

Investigations & Reports

Two separate investigations followed, and resulted in: — An in-house airline report; — A Police Report.

Findings 100

These reports were not shown to the author. However, the airline report considered that concerns “had been subject to a thorough investigation. These concerns101 were found to be unsubstantiated in all cases.” A later Police Report found that there had indeed been, as asserted, an altercation in the cockpit of the aircraft, during the flight, involving a cabin crew member. This investigation consisted of interviewing the crew by police. This was not an aviation-focused investigation ie did not consider Human Factors or Air Navigation Orders. It was therefore ad hoc, informal, and insuYcient. However, no agency has attempted to reconcile the disparities exemplified by these two responses. No explanation has been forthcoming from the airline to the bereaved—except denial and being told to “desist from speaking.” No safety lessons have been disseminated, and this investigation did not look at human factors systemic failings. 102 103 Research indicates104 that “systems that have not responded to the deficiencies raised in normal105 accidents have been doomed to repeat them.” In organisational safety, managerial levels are at least as important as technical failure and human error in causing accidents. Safety on board aircraft is dependent on Human Factors systems and Flight Deck confusion is cited in many aviation incident reports. Significantly, An investigation in 1994, following a near-miss, noted, “it appears that there is a level of animosity between the two crews that may be106 based on a lack of awareness and understanding of the duties of the other crew members during the flight . . . an analysis concluded that problems arose because of the “perception that the flight attendant is only answerable to the marketing department, making the chain of command on board the aircraft ineVectual.” 107 Dr Assad Kotaite, President of ICAO, has stated: “it is through the organisational perspective that we will break the current safety impasse . . . it is important to further the understanding of the root causes of both human and organisational error, and therefore, of the relationship between management and safety.”

CAA Response 108

The Response to the Report, “Civil Aviation; Civil War?” was flimsy—it did not respond to the points made in the report regarding safety. It was based on work done by discredited researchers, who refused to utilise the Protocol on Work-Related Deaths, refused to accept a complaint against the airline and did not (therefore?) apply ICAO Article 38.

100 101 102 AirlineAccidents. Spokesman IRIA pp February 10–18. 2005 Oxford Times. 103 Letter: 13 July 2004. DI W J Warner. Crime Manager, Gatwick, copied to Peter Gardner CAA. Struach.Research B Report. (2002) Normal Accidents—Yesterday and Today. Conference Paper. Investigating and Reporting of Incidents and 104 105 O’Dea, Angela and Flynn, Rhona (2003) The role of managerial leadership in determining workplace safety outcomes. HSE 41. No 4. July/August Flight Safety Foundation. 106 ICAO. RosenthalCabin Crew et Safety al (1994). Vol Flight 29. No Deck 2. March/April Confusion Cited 1994. in Flight Many Safety Aviation Foundation. Incident Reports. Human Factors and Aviation Medicine. Vol 107 108 Chute, Rebecca D and Wiener, Earl L, (1994) Cockpit and Cabin Crews: Do Conflicting Mandates Put Them On a Collision Course? the Freedom of Information Act. At a Plenary meeting of the Aviation Study Group, Linacre College, Oxford. 16 February 2001. See The Countess of Mar moved Amendment No 35: 8 December 2005; The author obtained the names of these researchers through 3844421033 Page Type [E] 30-11-07 13:08:37 Pag Table: LOENEW PPSysB Unit: PAG4

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CAA Response to utilise “Work-Related Deaths: A Protocol” 109 There was no process to determine whether this should be classed as a work-related death, delay, refusal. However, the CAA is a signatory to the Prosecutors Convention. The reason given for this refusal to use the Protocol on Work-Related Deaths110 was that they had another one! Thus, all the aforementioned steps were ignored and the process was short-circuited. A copy of this other protocol, a Memorandum of Understanding, was sent to Gwyneth Dunwoody. Neither of us could understand its rather Byzantine language. Our investigation foundered at this point. Significantly, two senior aviation medical personnel consider, and have oVered to testify, that the attack on the flight deck on the Captain, when he was seriously fatigued, and when he was landing at Gatwick, could trigger a heart attack (as per the Trident crash at Staines). This has not been oYcially investigated or addressed. Whether or not the early death of Captain Standing was caused by the event on board the aircraft, the Report, “Civil Aviation: Civil War?” exposes failings within the CAA, the airline and within the British Airline Pilots Association. All refused to discuss or consider the issues. The complaints procedure is flawed.

Conclusion The Committee “recommend(ed) airlines to review their systems and procedures for dealing with passenger concerns and complaints so that passengers do not feel that they are being forced to deal with lawyers and insurers from the outset.” This evidence demonstrates that the CAA and airline merely rubber-stamped a previously held view within the CAA, it ignored a Police Report (that there had been an altercation) and covered-up. Further, there is evidence that self-regulation does not work.

Comment The House of Lords Science and Technology Committee, “during its investigation into aviation health issues, identified a lacuna in that no regulatory body appeared to have111 any responsibility for the regulation and enforcement of health and safety issues on aircraft whilst in flight.” Neither the HSE nor the CAA see this as their job and the report notes that there appears to be a “marked reluctance on the part of the CAA to take on responsibility for occupational health and safety issues . . .” The conclusion must be that this leaves airlines with a free hand to ignore health and safety briefings for aircraft that are airborne.

Recommendations — That this lacuna be addressed immediately; — There should be a recommended named professional to liaise with the bereaved of air accidents and deaths at work in aviation.

Changes toCabinServiceProcedures 112

This section, “cabin service procedures” relates to how flight deck and cabin crew work113 together in the operating environment in order to maintain safety. It is in two parts, the first regarding human factors, and114 the second relates to the physical environment. The reason for the inclusion of these together is systemic: the eVects of stress are cumulative and include physical, mental and emotional factors. Further physical stressors have been reported regarding toxic eVects of chemicals on aircrew, leading to pilot incapacitation. Death has been recognised as a consequence of stress since the concept was first described. “Although the mechanism of this dramatic sudden death is not clearly understood, it is most probably due to abnormalities of cardiac rhythm induced by nervous stimuli . . . (there are) case reports . . . attributed to physical or

109 110 111 112 Letter dated 16 April 2003. Neil Masters. Senior Policy Advisor. CPS. LetterSafety. 27 Vol June 27No 2003 6. to November/December Dunwoody, copied to 1992. T Walker. Flight Safety Director Foundation. General. 113 Henderson, Graeme. (2002) Enforcement of Health and Safety on Aircraft. Health and Safety Commission. HSC/02/54. 114 Edwards. M, (1992) Crew Co-ordination Problems Persist, Demand New Training Challenges. Flight Safety Foundation. Cabin Crew Authority Thirteenth Report of Session 2005–06. House of Commons Transport Committee, The Stationery OYce. Selye 2000. Standing, C (2005) The Aviation Safety System. Political, Organizational and Personal. Appendix 39 in The Work of the Civil Aviation 3844421033 Page Type [O] 30-11-07 13:08:37 Pag Table: LOENEW PPSysB Unit: PAG4

air travel and health115 : evidence 141 116 emotional stress resulting in an acute alarm reaction.” More recent work has confirmed these early findings. 117 Clearly, “stress management is an important part of Crew Resource Management because it aVects the operational eVectiveness of the team . . . Under no circumstances should either excessive workload or excessive stress jeopardise the safety of a flight.”

Cabin Environment. Human Factors

The above Case Example includes scientific evidence from psychological and human factors research.118 Anecdotal evidence from pilots indicates that there are ongoing safety problems between pilots and cabin crew. This is confirmed by safety reports in the Confidential Human Factors Incident Reporting (CHIRP) A brief review of CHIRP would demonstrate that known problems still exist, and are ignored, in UK airlines. We can speculate that that either scientific evidence is being ignored; or airline practices, reviewed from within the industry: (a) are unavailable to Oxford University Science libraries; (b) lack transparency; (c) are not peer reviewed in reputable journals. 119 Cabin Services are reliant on procedures such as recruitment, training, and accountability of suitable staV. Research also demonstrates that organisational factors, how the airline organises their departments and how departments relate to each other, also eVects safety in the working environment.

Cabin Environment: physical health—pilot incapacitation The Committee asked, “To what extent has the aircraft cabin environment improved?” A brief timeline will illustrate whether research and protocols have improved the cabin environment. 120 1977:“A previously healthy member of an aircraft flight crew was acutely incapacitated during flight with neurologic impairment . . . The etiology of his symptoms was related to an inhalation exposure to aerosolised or vaporised synthetic lubricating oil arising from a jet engine of his aircraft.” 1999, February: Organophosphate lubricants were the focus of a question regarding “possible health hazards for air crews [66599]. 121 Mr Doug Henderson, responded, “We . . . have in place a number of preventative measures to prevent air and ground crews from being exposed to these hazards and also regularly review the health risks.”

2001 March: the cockpit of a British Aerospace 146 filled with toxic fumes. A sudden and unexpected122 Airworthiness Directive was issued. Close inspection of this reveals a vague reference to a previously unreported “recent crew incapacitation123 incident in the UK” details of which Private Eye established. It had taken this non-industry magazine to review the health risk and establish what the industry couldn’t see. 2001: Aerotoxic Syndrome Identified. Symptoms identified in the short-term include: — neurotoxic symptoms: loss of consciousness, blurred or tunnel vision, nystagmus, disorientation, shaking and tremors, loss of balance and vertigo, seizures, parathesias; — neuropsychological symptoms: memory impairment, headache, light-headedness, dizziness, confusion and feeling intoxicated; — gastro-intestinal symptoms: nausea, vomiting; — respiratory symptoms: cough, breathing diYculties (shortness of breath), tightness in chest, respiratory failure requiring oxygen;

115 116 production management (Sixth Draft for International Journal of Health Services) 4 February 1997. 117 Selye 1984:212. 118 Nishiyama, Katsuo, and JeVrey V Johnson (1997) Karoshi-Death from overwork: Occupational health consequences of the Japanese 119 Orlady.Cabin Crew H W Safety (1999). Vol Human 29. No Factors 2. March/April in Multi-Crew 1994. Flight Flight Operations. Safety Foundation. Ashgate. :281–282. 120 http://www.chirp.co.uk/main/default.asp Chute,to Synthetic Rebecca JetLubricating D and Wiener, Oil. Earl Clinical L, (1994) Toxicology Cockpit 11(4), and Cabin p 423–426) Crews: Do Conflicting Mandates Put Them On a Collision Course? 121 122 Montgomery, Mark R, Wier, Thomas G, Zieve, Franklin J, Anders, MW, (1977) Human intoxication Following Inhalation Exposure 123 HoldingOccupational answer Health 19 January & Safety— 1999]Australia (Hansard and). New Zealand, Vol 17, October 2001. http://www.aopis.org/PrivateEye6July2006.pdf Winder, C and J C Balouet (2001) Aircrew exposure to chemicals in aircraft: Symptoms of irritation and toxicity The Journal of 3844421033 Page Type [E] 30-11-07 13:08:37 Pag Table: LOENEW PPSysB Unit: PAG4

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124 — cardiovascular symptoms: increased heart rate and palpitations; — irritation of eyes, nose and upper airways. 2001: When pilots were taken to hospital post-flight, the CAA belatedly admitted what the industry and others already knew: — Pilot incapacitation exists; — Fumes pose a danger to both passengers and crew. 2005: Dr Ruge, a member of the AHWG in referring to the UK Government and CAA-initiated and sponsored research paper Cabin Air Quality published in 2004, stated: “The results did not suggest that there is a health risk for passengers, including infants, and crew”. That paper reveals that: ”The research described in this report addresses the eVect of cabin air contamination on the pilot’s ability to safely fly and land an aircraft.” (ie not infants or crew). 125 The Countess of Mar notes: “The research paper relies heavily on a BAe ”Commercial—in confidence” paper by Marshman and neither paper has been peer-reviewed nor published in a scientific journal, and yet they seem to be accepted as gospel.” 2007, 20 February: Lord Tyler asked Her Majesty’s Government: What consideration they have given to introducing regulations on the installation of contaminated air detection systems in United Kingdom registered aircraft? [HL1947]

Lord Bassam of Brighton: The principle of better regulation is to legislate only where necessary. It is126 not clear that contaminants are present in the cabin environment in a quantity harmful to crew and passengers. That is why we asked the independent Committee on Toxicity (COT) to undertake a comprehensive review of all the evidence, and we will, of course, be guided by the COT’s conclusions and recommendations.”

127 Comment This is not a comprehensive list; it represents key milestones in the history of cabin air incidents. In the light of all the evidence regarding toxicity in BAe aircraft, Lord Bassam’s response reveals that he is: — ignoring up-to-date scientific evidence already in existence since 2001; — unaware of the concept of a proactive safety system as advocated by the International Civil Aviation Organization (ICAO); — unaware of “slippage”. Where an organisation had once learned its lessons, and applied the science, some will slip back into old and favoured views. Furthermore, — The UK is a member state of ICAO and domestic legislation should reflect ICAO standards; — Given the former reference to discredited scientists this assurance fails to impress; — On the recommendation to use the independent Committee on Toxicity (COT), I repeat the words of the Countess of Mar: ”These expert committees are often required to make decisions upon incomplete evidence, so the only verdict they can give is that of ”not proven”. This cannot be an impartial response if the resources allocated to field and clinical128 investigations are inadequate and the evaluators do not qualify their findings accordingly. They rely upon what may be called ”constructive ignorance” by being content to rule on the evidence which is before them and avoid a search for information that may lead them to a diVerent decision. That is not being impartial.”

Conflicts of Interest?

The Countess of Mar has highlighted how “the Government in its attempt to bury this issue (of129 organophosphate poisoning) have passed the vast volume of data supplied to them by the pilot union BALPA, to a team under the leadership of Professor Alan Boobis. Professor Boobis is a well known advocate that chemical exposures are all safe, despite this being a diVering view to that held by the Royal Commission.” He is also a member of COT—the Committee on Toxicity.

124 125 126 127 This list appears at http://www.aopis.org/shorttermsymptoms.html 128 Hansard, House of Lords. 8 December 2005 : Column GC133 Lady Mar. 129 Hansard, House of Lords. Aviation: Air Quality: Column WA215 Lady Mar. For a comprehensive list see Michaelis, S, (2007), Aviation Contaminated Air Reference Manual. Hansard, House of Lords. 27 June 1997 at Column 1559. Lady Mar. Hansard, House of Lords. 8 December 2005: Column GC133 Lady Mar. 3844421033 Page Type [O] 30-11-07 13:08:37 Pag Table: LOENEW PPSysB Unit: PAG4

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“Confidential documents disclose that former Environment Minister Michael Meacher and Food and Farming Minister130 Lord Whitty, were deeply concerned that scientists with industry links were dominating committees on everything from food safety and air quality to the imminent arrival of GM crops. Both Meacher and Whitty were alarmed that the scientists’ commercial links jeopardised the independence of the advice they gave.” Tony Juniper, director of Friends of the Earth, said: “It is now crystal clear how big business is setting the agenda right at the heart of government. The whole process needs to be opened up and made transparent. How can the public trust what Ministers say if their advice is coming from those with vested interest in the biotech or pharmaceutical industry.” “Boobis named in shaming document.” It was noted that, “Dozens of the Government’s most influential advisers on critical health and environmental issues, including cabin air, have close links to biotech and drug corporations, according to a dossier of Whitehall documents obtained by The Observer”.

Conflict of Interest v Bias? “Of course there is also an inherent bias in that human nature decrees131 that arbiters tend to favour their own judgment and resist the opposite view. The Cairns Committee in its review of the authority which both licensed aircraft as airworthy and was responsible for investigating aircraft accidents coined the phrase ”intellectual corruption”—[OYcial Report, 24 June 1997; col 1558–9.]”. Dr Sarah Mackenzie-Ross, consultant clinical neuro-psychologist at UCL, has used the CAA database to estimate as many as 197,000 passengers in 2004 may have been exposed to such fumes. She said: 132 “the levels of toxic chemicals in the blood were higher than population averages. All of the pilots reported chronic health problems, including fatigue and gut problems, and numbness in their fingers and toes. They all suVered memory loss and diYculties in retrieving words.” 133 In contradistinction to the scientific evidence, and to Human Factors principles, the airline industry asserts that, “any organophosphates that enter an aircraft are in such small doses as to be insignificant.”

Comment In this paper we see mortality and morbidity in aircrew. On one hand, we see qualified experts expressing one set of views, and on the other hand, unqualified persons, and persons with conflicts of interest, asserting otherwise. This ad hoc response has lead to: — the unfortunate and distressing misdiagnosis of crew who have been poisoned; — the lack of a comprehensive safety system. Deficits include: — Findings that are still not addressed systemically; 134 — Findings that are not based on hard science; — Delay: An airline has still not complied with terms of settlement in a case of toxic poisoning; — Slow Government responses. 135 In addition, with the reduction of the safety research budget there is concern that, “the ability to undertake research into emerging aviation technologies as well as investigating innovative approach to safety management systems was an essential capability of the CAA’s Safety Regulation Group.”

AFinalWord—TheTombstoneImperative A short document is not the place to argue the dynamics of how and why research evidence regarding safety failings mentioned in this paper have not been addressed, or is subject to procrastination. Nor why the research papers on the body of aviation research is not published openly in scientific peer-reviewed journals. We are currently simply accepting casualties: In the US, “the FAA has proposed a voluntary system of reporting and is ‘urging’” the industry to implement it: Rather than overcome the legal and commercial obstacles in a manner which places the safety of the travelling public at the top of the agenda, they have opted for yet another voluntary code of practice. Requests

130 131 132 133 Antony Barnett and Mark Townsend Sunday July 13, 2003. The Observer. 134 Hansard, House of Lords. 8 December 2005: Column GC133. Lady Mar. 135 http://www.aopis.org/PrivateEye6July2006.pdf ibid. This is the case of pilot incapacitation mentioned in Standing (2006). The Work of the Civil Aviation Authority; Thirteenth Report. House of Commons Transport Committee para 39. p 16). 3844421033 Page Type [E] 30-11-07 13:08:37 Pag Table: LOENEW PPSysB Unit: PAG4

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136 for the industry to improve its act voluntarily have rarely worked in the past, so there is little reason to suppose this will do any better.” This sounds familiar to UK ears with its self-regulation.

“Airplanes and helicopters crash, crew members and passengers137 are killed, horrendous liability and damage litigation and unbelievable grief and suVering continues because, for whatever reason, there is still insuYcient feedback, open exchange of technical information on a worldwide basis, thorough investigation of seemingly minor operational occurrences or mechanical anomalies.” The term, “The Tombstone Imperative”, was used originally as a chapter heading quoting Barry Sweedler, one of the senior oYcials of the National Transportation Safety Board, which supervises aircraft safety in the USA. He is recorded as saying, “We regulate by counting tombstones.” It reflects138 the fact that, “changes to the safety of modern aircraft are only made when a cost-benefit analysis has been done in which the cost of the new safety measure is balanced against a notional figure for the monetary value of a life. If the cost of the measure exceeds the “value” of the lives saved, then it won’t be implemented.”

The lives of our children don’t count in monetary terms. (Sadly, and painfully, for those who lost a child in the Manchester disaster.)

It is within our means to prevent increasing numbers of tombstones.

Conclusion

This paper has been about new developments in aviation health that have emerged since 2000, and the extent to which Government, regulators and the airline industry have kept pace with such evidence. The finding of this report are: — The safety system, as described in this paper, demonstrates an ad hoc system that does not integrate with known papers supplied by ICAO’s work on Human Factors, nor on the scientific advances being made in Australia and New Zealand—that of Winder and Balouet; — Government responses do not reflect the urgency of the situation (given the pain, ill-health, and suVering caused to airline pilots and their families—the antithesis of well-being documented in Human Factors research); — Government responses do not reflect the urgency and danger to the public, where toxic fumes eVect: — the very elderly, pregnant women, and the very young; — other vulnerable passengers (recovering from serious illness but fit to fly); — two pilots simultaneously; — a single-pilot operation; — Mortality/morbidity. Alarming deficits in Health and Safety are now matched by the lack of justice for victims—the Tombstone Imperative; — UK Airline Pilots’ mortality/morbidity—what are the figures? Are they arrived at through Evidence- Based Practice? — It is unknown whether the lacuna that existed between the Civil Aviation Authority and the Health and Safety Executive still exists; — On the subject of research into aviation health and safety, transparency and accessibility to current aviation-industry research is imperative. Current, publicly available, academic work in aviation Human Factors and Systems Theory is not yet of the standard Oxford University stocks; — There is no integrated system; — None of the cases cited in this Report has been progressed to satisfactory outcomes—ones which acknowledge mistakes and use their lessons learned in a proactive system in order to safeguard the public and crews’ health. (Despite available research recommendations from elsewhere).

136 137 138 Weir, Andrew (2000) The Tombstone Imperative. Simon and Schuster:252. Rudy Kapustin in Weir 2000: 264. Weir 2000:1. 3844421033 Page Type [O] 30-11-07 13:08:37 Pag Table: LOENEW PPSysB Unit: PAG4

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Recommendations

Safety Research in Human Factors On the questions about “More research into the health eVects of air travel” and “Changes to Cabin Service Procedures” there is no doubt that more up-to-date, scientifically-based research is needed. However, this paper also notes that current research is being ignored. This, by people outside the safety system, (MPs, Government scientists, untrained managers) who have the wherewithal to bring a negative influence into that system. This subject can seem to be amorphous, however, when integrated with other disciplines, and sometimes endorsed by law and accountability, clear and safe protocols are developed. 139 — “What is needed is a small, independent, expert organisation that has the trust of aircraft manufacturers, airlines and employees. Trust is the most important thing. Without trust, we might as well forget Clause 7 and go on as before.” — Such an organisation has been outlined by the Countess of Mar: A Civil Aviation Occupational and Environmental Medical Monitoring and Action Centre (CA-OEMMAC); — Such an organisation could inform the Royal College of General Practitioners of trends in aviation- related illness, such as Aerotoxic Syndrome, SARS, and Tuberculosis; — Evidence-based practice should be established and monitored in aviation safety management; — Hard evidence should inform practice rather than ad hoc views; — There should be a fully independent (independent of any industry ties), “ombudsman” with regard to complaints about health and safety issues, and failure to publicise and apply the Protocol on Work Related Death; — The will to prevent more tombstone imperatives; to avoid non-natural disasters. 18 June 2007

Memorandum by Thomsonfly TUI NE is the UK holding company of the group of companies that includes the UK tour operator and retailer, TUI UK Limited and the UK’s third largest carrier in terms of fleet size, Thomsonfly Limited. Thomson Holidays is the main tour operator brand of TUI UK and is the UK’s largest inclusive tour operator and Thomsonfly carries all Thomson Holiday passengers and a further 2 million seat only passengers annually. Thomsonfly is also the largest UK Charter Airline operating a fleet of 47 aircraft from 26 UK airports to 84 overseas destinations. Thomsonfly carried 9.5 million passengers in 2006 and operated over 60,000 sectors. Thomsonfly is also a member of the British Air Transport Association. Thomsonfly believes the industry has made a great deal of progress since the original report and the establishment of the Aviation Health Unit has been a very useful initiative. There are still a number of areas where Thomsonfly believes the industry would benefit from more support and timely responses to queries, from the AHU but generally the unit has provided an impartial and objective source of information for aviation health. The CAA’s Aviation Occupational Health & Safety Steering Group (AOHSSG) currently works well with industry and is the primary contact point for Thomsonfly for many queries within this area. There is limited understanding as to how the AHU fits in with the AOHSSG and as the nature of the CAA as an organisation is one that does not readily volunteer information we would suggest that the AHU should consider raising its profile within the industry and should ensure a regular contact program with the UK based airlines to ensure an increased level of self promotion. Two examples of where we believe the AHU could be of great assistance to the industry would be the current concern around fatigue in pilots and the quality of cabin air. There has been a lot of concern raised about organophosphates in engine oils and the impact to health if the air breathed by passengers, flight deck and cabin crew contains these chemicals. Studies to date have not had independently certified data and have produced results that are diYcult to interpret and that have not been accepted by the aviation medical fraternity. Recent media reports (appendix A) have claimed there is overwhelming evidence and that the industry continues to deny the problem exists. Airlines are responsible for the health and safety of our staV and we need conclusive evidence to decide what the main concern is and how best to look at a solution going forwards. Thomsonfly, along with many other UK registered airlines

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146 air travel and health: evidence would welcome and would be prepared to actively participate in a properly designed study into the area of concern. To try and address this issue Thomsonfly has agreed to voluntarily participate in a study at Cranfield University on cabin air quality. This study was initially proposed by the DfT and we believe tests on equipment to be used are currently being carried out but we believe given the media interest in this area that more active communication to ensure the airlines are aware of the process of this trial should be employed. Thomsonfly believes that the AHU could help the industry by ensuring this trial takes place and that it takes place soon. Thomsonfly believes the AHU should work with the industry and should take the lead in actively addressing issues such as fatigue and organophosphates before they become “news” items. A regular dialogue and an attitude of action rather than reaction could have helped the industry to progress towards solutions for both of these issues. Many of the UK airlines employ their own medical advisor. Thomsonfly has our own medical advisor and although the Airline Medical Advisors do in fact have regular contact with the AHU we would appreciate some formal guidance on how medical advisors fit within the AHU structure. However, Thomsonfly would not be prepared to give up our own advisor even if this was clarified as we do not believe the AHU can provide the detailed response, the level of service, the speed of the service and the understanding of our business that we currently receive. Thomsonfly has made great eVorts to ensure the information that is available to travellers is comprehensive. Thomsonfly includes a video on longhaul flights about DVT and health whilst travelling on our in flight entertainment, there is a warning about DVT in brochures, ticket booklets, in flight magazine and on our website. The issue of DVT is one that has been associated with confinement and so Thomsonfly believes a well designed study that compares, train seats, cinema seats and lorry drivers etc should be undertaken by the Aviation Health Unit in conjunction with the industry. This would be of assistance to the industry and provides the sort of lead on these issues that Thomsonfly believes the AHU should be taking. All Thomsonfly aircraft are equipped with first aid kits and a doctors kit that can only be opened with the captains’ permission, and used by a doctor, paramedic or nurse. In addition to this Thomsonfly long haul and medium haul aircraft also have a 24 hour radio link to a medical service (medi-link) that can be reached in the event of an in flight emergency. This service will provide information from answering general medical queries to providing specialist information to crew and medical professionals to help in a number of medical emergencies and has helped to reduce the number of emergency diverts by 50%. The short haul aircraft will usually be able to divert to a local airport in the event of an onboard emergency. The same 24 hour medical service is also available by telephone to crew and engineers when they are overseas and have a health related query. We also have a 24 hour holiday line that is available to customers on holiday where they can obtain advice on a variety of issues, including how to access local medical assistance once overseas. As Thomsonfly is the in house airline for Thomson Holidays, in the event of an in flight medical emergency we are well placed to be able to co-ordinate rebooking of holidays, refunds of accommodation costs and being able to provide English speaking representatives at many of our overseas arrival airports to deal with friends and families of those passengers who may have experienced an in flight medical emergency. Thomsonfly carried over 9.6 million passengers in 2006 on approx 45,000 flights and we estimate that the medi- link service was used 3 or 4 times a week. These can range from just asking a query about a passengers high temperature to a more specialist area such as a suspected miscarriage. Defibrillators have also been fitted to all aircraft in the fleet and all cabin crew are trained and tested annually on how to use this equipment. The defibrillators are used on average about five times a year on board the aircraft and have even been used on a baggage handler who had a heart attack and also on an air bridge to assist a passenger. Thomsonfly has noticed an increase in the number of deaths on board that has risen from about two passengers a year in the 1990s to about four a year. There has been significant growth in passenger numbers which would account for a proportion of this increase but it is still import to note this increase occurred even though Thomsonfly has fitted defibrillators and should be considered if the decision to make defibrillators a mandatory item is being discussed. Thomsonfly also makes regular public announcements during the flight to ensure passengers look after their health during a Thomsonfly flight. These announcements encourage passengers to move their legs and drink lots of water, on our long haul aircraft water fountains are fitted for the convenience of the passengers. 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Thomsonfly will also be purchasing the new 787 aircraft which has an improved internal environment which has been designed by Boeing to improve a passengers experience and enjoyment of the flight. The cabin environment has larger windows and has a greater feeling of openness and airiness that should improve the passengers’ experience. A new health concern that has risen since the last report is the issue of flu pandemic and communicable diseases. Thomsonfly has been fully involved in governmental discussions on formulating the NHS plan and the potential concerns surrounding air travel as well as ensuring our own flu pandemic plan is in place and senior staV are aware of its content. We do however believe the AHU should consider looking at communicable diseases and providing reasoned advice to airlines on what further measures could be taken to reduce any spread either during a pandemic or in the rare occasion that we would undertake a medical evacuation flight. All aircraft are deep cleaned after medical evacuation flights but it is during the actual flight that Thomsonfly feels some further investigation undertaken now might benefit the industry within the next few years. Thomsonfly believes the industry has made some significant advances since the previous report. The number of passengers requiring medical assistance do remain low as the numbers of instances that require use of the medi-link service show. Thomsonfly would be happy to assist the Committee in providing further evidence if so required. 29 June 2007

Memorandum by Unite the Union—Transport and General Workers’ Section

Introduction The Transport and General Workers’ Union (T&G) and Amicus Sections of UNITE—the Union is the largest trade union representing cabin crew staV working on United Kingdom registered commercial aircraft. We welcome the invitation by the Select Committee for “evidence on the health eVects of air travel” and we would like to specifically address concerns about the Aviation Health Working Group (AHWG) and then a brief comment on cabin air quality. This area is being covered in more detail in a submission by one of our members who is an H&S representative working in the civil aviation industry.

Background to theAviationHealthWorkingGroup The responsibility for the policy on air transport issues lies with Health and Safety Executive’s (HSE) Special Transport Sectors Unit. This is part of HSE’s Policy Group’s Civil Contingencies and Special Sectors Division. The HSE’s main responsibility is for policy in relation to ground operations at UK airports. However, because the Health and Safety at Work (HSW) Act also applies to aircraft in Great Britain’s airspace, the HSE also needs to consider the eVect of the application of health and safety legislation to aircraft in flight. Unfortunately the HSE does not seek to enforce the HSW Act in relation to aspects of aviation health and safety which are the current remit of the Civil Aviation Authority (CAA). There is a Memorandum of Understanding (MOU) between the HSE and the CAA which established a framework for liaison between the HSE and the CAA Safety Regulation Group (SRG) which was supposed to ensure eVective co-ordination on policy issues, enforcement activity, and investigation in relation to CAA/ SRG and HSE responsibilities for safety in relation to aircraft and the systems in which they operate. In the Fifth Report of House of Lords Select Committee on Science and Technology published in November 2000 one of the recommendations to Government was that a central source should be given responsibility for advising Government on the issues relevant to aviation health. The Department for Transport (DfT) consulted the aviation industry and other interested parties with a number of options, the preferred one of which was to give responsibility to the CAA. As a result of the consultation in 2003, the DfT asked the CAA to set up the Aviation Health Unit (AHU). We would draw the Committees’ attention that at the time the T&G opposed this. We believed then and still do that the HSE is the appropriate “central source be given responsibility for advising government on the issues relevant to aviation health” not the DfT. This was not a criticism of the DfT as we work with the Department almost on a daily basis. It is just that we believe that in this instance the HSE is and should be the competent authority. 3844421035 Page Type [E] 30-11-07 13:08:37 Pag Table: LOENEW PPSysB Unit: PAG4

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Despite our concerns the AHU was formed on 1 December 2003. Based at Gatwick within the Civil Aviation Authority’s (CAA’s) Medical Department, its main role is to advise government, through the Aviation Health Working Group (AHWG), on passenger and crew health issues. As this is a diVerent requirement from the safety regulation role of the CAA, the DfT retains responsibility for any policy changes arising from health recommendations. From 1 April 2007 the AHU’s funding has been provided by industry in common with the other functions of the CAA. The AHWG is an interdepartmental organisation, chaired by the DfT, with representatives from the CAA, HSE and the Department of Health. We have major reservations about the funding of AHU which is being provided by industry. Health and safety funding should be separate and140 independent from any overt or covert influence of the funding providers. Despite the Draft Mission Statement for the Aviation Health Working Group which states: “The Aviation Health Working Group will meet on a regular basis and will work in partnership with other interested parties to give eVect to the Government response to the House of Lords Inquiry into Air Travel and Health.” According to the CAA website the AHWG meets every two months to discuss issues relevant to aviation health and was instrumental in the decision to form the AHU. At alternate meetings, industry and passenger representatives attend. However, it is not our experience that the AHWG has met on a regular basis. A search of the DfT website resulted in minutes for the two last meeting of the AHWG dated 4 April 2006 and 23 April 2007. Nor do we believe it has it worked eVectively in partnership with other interested parties within the industry. A specific example of the latter is the Independent Pilots Association (IPA) which was prevented from joining the AHWG. The IPA and the British Airline Pilots Association (BALPA) are the only other UK unions representing flight crews in the UK. The IPA is an interested party in all issues relating to aviation health and safety issues relating to cabin crew so we find it diYcult to understand why they have been prevented from joining the AHWG. The T&G Section of UNITE—the Union has been a member of the Aviation Health Working Group since 2004 and drawing on this experience we firmly believe there is an ongoing need for a simple and eVective communication system about Aviation Health issues. We believe it is of paramount importance that this communication system is facilitated by regular meetings of the AHWG.

AirCabinQuality The T&G Section of UNITE—the union take the issue of the health and safety of its members, and indeed the travelling public, very seriously. We remain very concerned that the breathing air supply to the cabin, provided by bleed air, is delivered completely unfiltered and that this and any re-circulated air is not monitored to ensure it is ”free from harmful or hazardous concentrations of gases or vapours.” Currently the detection of potentially contaminated air relies on the sense of smell of the air crew and we believe that is totally unacceptable. Currently there is no requirement for air crew, either cockpit or cabin, to be tested during their mandatory medical for a minimum level of sense of smell. Until proper standards are introduced contaminated air events will continue to occur on commercial aircraft creating potentially dangerous situations for both passengers and crew.

Conclusion We are asking the Committee to recommend that the AHWG should meet on a more regular basis and to be inclusive in regard to the composition of the working group. The HSE should become the competent authority for civil aviation health and safety and not the CAA. There is a need to establish a simpler and eVective communication system dealing with aviation health and safety issues. We are asking for proper standards to be introduced to prevent contaminated air events. June 2007

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Letter from H&S Representative T&G section of Unite the Union You may be aware that Unite the Union is the only union representing cabin crew staV on British registered commercial aircraft and has been a member of the Aviation Health Working Group since 2004 as the Transport and General Workers Union. This evidence enhances that submitted by the Transport and General Workers Union (T&G) and Amicus Sections of Unite—the union on Cabin Air Quality. Further to the invitation by the Select Committee for “evidence on the health eVects of air travel” we would like to specifically address concerns about the eYcacy of the Aviation Health Working141 Group(AHWG) and cabin air quality. Despite the Draft Mission Statement for the Aviation Health Working Group stating: “The Aviation Health Working Group will meet on a regular basis and will work in partnership with other interested parties to give eVect to the Government response to the House of Lords Inquiry into Air Travel and Health.” the AHWG has not met on a regular basis nor worked entirely in partnership with other interested parties. On the latter point the Independent Pilots Association, prevented from joining the AHWG unlike the British Airline Pilots Association who are able to attend, is the only other UK union representing flight crew. They are very much an interested party in all aviation health issues. We firmly believe there is a continuing need for simple and eVective communication about Aviation Health and it is of paramount importance that this be facilitated by regular meetings of the AHWG. As to cabin air quality it is noteworthy that whilst the House of Lords Report (HL Paper 121) called for: “9.3(c) real-time monitoring of air quality (see paragraph 5.50) and other aspects of the cabin environment, with a view to establishing new and clear regulatory minima142 for passenger cabin ventilation” the lack of equipment capable of undertaking this task was emphasised over 5 years ago at the meeting on 16 October 2002 chaired by Peter Smith: “On the ‘collection of basic cabin environment data’ [recommendation 1.25), Nigel Dowdall outlined the lack of available equipment to provide the sort of ‘routine monitoring’ recommended by the House of Lords. He indicated that material had been published on a number of websites including BA’s, Boeing’s and also in a number of articles and journals. He also confirmed that this material would include some of the routine data continuously monitored on-board flights. The Secretary confirmed that MLD had received a list of websites from BATA, and the Chair concluded that this action point had been achieved.” and, it is understood, nothing has changed. At paragraph 3.33 the House of Lords Report stated: “Until 1996, both FAA and JAA had the same basic requirement for cabin ventilation rates. FAR 25.831 and JAR 25.831 required a minimum supply of 10 cubic feet per minute (cfm)[26] [27] of fresh air per flight crew member, which ‘must be free from harmful or hazardous concentrations of gases or vapours’ with specific maximum concentrations for: — carbon dioxide at 5,000 parts per million by volume (ppm)[28]; — carbon monoxide at 50 ppm; and — ozone at 0.1 ppm (short-term emergency maximum 0.25 ppm).” and yet, to this day, carbon monoxide detectors are not fitted to commercial aircraft and in answer to a written question by Lord Tyler the Government have indicated they have no intention of ensuring such detectors are fitted in the majority of commercial aircraft: “Lord Tyler asked Her Majesty’s Government: What steps they have taken to ensure that carbon monoxide detectors are fitted in aircraft to enable the commander to monitor emissions. [HL1941] Lord Davies of Oldham: The Civil Aviation Authority (CAA) has recently drafted a European Technical Standards Order (ETSO) that provides an up-to-date technical specification for a carbon monoxide detector for aviation use. This draft ETSO has been submitted to the European Aviation Safety Agency (EASA) with a recommendation for adoption as a European standard. At the same time the CAA submitted a proposal for changes to EASA’s certification specifications that would mandate the installation of carbon monoxide detectors in future aeroplane designs.

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These proposals were made as a direct result of experience of accidents, and they were supported by a preliminary Regulatory Impact Assessment. The proposals, if adopted, would require installation of carbon monoxide detectors only in single-engined aeroplanes with forward mounted engines, since the world-wide experience of accidents and incidents does not support the need for installation of carbon monoxide detectors in other aircraft.” Government further confirmed that aircrew relied on their sense of smell to determine whether a contaminated air event was taking place and that there is no requirement for fitting air quality monitoring equipment, or for air crew to be tested during their mandatory medical for a sense of smell: “The Countess of Mar asked Her Majesty’s Government: Further to the Written Answer by the Lord Davies of Oldham on 19th October (WA 126), how, in the event of a system failure and a contaminated air event occurring, aircrews know that such an event has occurred in the absence of monitoring devices when the contaminated air is caused by compounds, such as carbon monoxide, that have no odour. [HL2313] Lord Davies of Oldham: In the absence of odour, and in the absence of any discernible eVects, aircrew will not know that a contaminated air event has occurred. In such a case reliance is placed upon routine maintenance actions to find and fix the system failure. The Countess of Mar asked Her Majesty’s Government: Why contaminated air detection systems are not fitted to all British commercial aircraft. [HL1641] Lord Davies of Oldham: There are no statutory requirements for the fitting of air quality monitoring equipment in aircraft. Such equipment is not required because aircraft ventilation systems are designed to supply air of an acceptable standard. This is confirmed at initial certification and each aircraft is subject thereafter to scheduled maintenance actions to ensure those standards are maintained. Air quality monitoring exercises have confirmed the acceptability of cabin air supplied. Where problems are encountered in service these are investigated and changes are introduced as necessary.” In consequence, it is quite clear that, despite specific maximum concentrations for ozone, carbon monoxide and carbon dioxide being stated (3.33), there is still no real time equipment installed to monitor, control, or warn flight crew if these levels are exceeded. Additionally, there is no warning possible of a contaminated air event when substances hazardous to health, such as Tri-cresyl phosphate (TCP), enter the cabin. Furthermore, and relevant to the House of Lords Report (9.3(e)), there has been little consideration of the synergistic eVects posed by chemicals: “The Countess of Mar asked Her Majesty’s Government: What exposure standards currently apply to any synergistic eVects of simultaneous exposure to numerous chemicals which may be experienced by aircraft passengers and crew during a contaminated air event in a reduced pressure environment. [HL1761] Lord Davies of Oldham: None. European airworthiness regulations for aircraft and engine design are written in objective terms that stipulate that the air provided to the passenger and crew compartments must be free from harmful or hazardous concentrations of gases or vapours.”

InConclusion 1. The T&G take the issue of the health and safety of its members, and indeed the travelling public, very seriously. We remain exceptionally concerned that the breathing air supply to the cabin, provided by bleed air, is delivered completely unfiltered and that both this supply and any recirculated air is not monitored to ensure it is ”free from harmful or hazardous concentrations of gases or vapours.” Current detection of potentially contaminated air relies on the nasal passages of the crew and that is not acceptable. Contaminated air events continue to happen on commercial aircraft. 2. We trust the AHWG will meet on a regular basis and will work in partnership with other interested parties. 17 June 2007