House of Lords - Science and Technology

Select Committee on Science and Technology Written Evidence

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 suffered short or long term medical effects 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).

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.[5] 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'etre: 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 effect 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 effects 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 vaporized or aerosol synthetic lubricating oil from contaminated bleed air. Symptoms included headache, nausea, dizziness, vomiting, inco-ordination, lethargy, difficulty standing etc. The report concludes "Further investigation into the potential hazards from inhalation of synthetic oil fumes... is definitely warranted".[6]

1981: Society of Automotive Engineers (Aerospace),[7] "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 degC this oil breaks down into irritating and toxic compounds".

1983: Mobil: "If cabin air becomes contaminated with any lubricant and / or its decomposition products, in sufficient 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".[8]

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 supply system.

1990: BAe Service Information Leaflet: "Operators have been reporting an increasing number of hot oil smells in the passenger cabin".[9]

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.[10] These include manufacturer 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.[11]

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 effects 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 affected 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 flight 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 very extensive inquiry in 1999 and 2000 specifically looking at the contaminated air problem on the BAe 146.[12] 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.[13]

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 suffered 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;

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 effects (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:

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:

Mr Dick Best a former CASA Airworthiness Officer who issued the BAe 146-300 its Certificate of Airworthiness in Australia, strongly disagrees with the CAA interpretation of JAR 25.831 a/b.[17] Additionally, Mr Stephen James, Head of Mechanical & Fluids Systems, SRG at the CAA, advised publicly in 2003[18] 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 suffering irritation with no impairment such as nausea and headaches or irritation of the eyes, nose and throat.

Given that globally various regulations and directives list fire explosion, smoke or toxic or noxious fumes as reportable incidents,[19] 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 / effect on efficiency to duties, yet not all effects might be reported. The less serious effects such as headaches, nausea and discomfort ought not to be passed off by the CAA as "comfort issues" for which they have no responsibility 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".[20]

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.

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.[21],[22] 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

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[23] and by the BALPA 2002 survey.[24] 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 telling the CAA that less than 10%, at best, of the lower intensity contaminated air events were being reported due to crew pressure 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[25] yet the BALPA 2002 survey information shows this figure to be grossly incorrect. 20 The CAA claim events are decreasing[26] 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 partly 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".[27]

Example—Failure to investigate the scale of health effects in crews

There are a growing number of crews reporting short and long term health effects following contaminated air events, supported in many cases by extensive medical documentation from their doctors[28] related to exposures to contaminated air by crews who fly the BAe 146, Emb145, 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.[29] Some of the findings presented at the BALPA conference showed clear parallels with Gulf War Syndrome, exposure to sheep dip and other organophosphates. Why has the CAA never taken the initiative to see the extent of medical effects in crew members? When the CAA Chief Medical Officer suspended a pilot's medical certificate in 2000 based on the view of his consulting neurophysiologist that the pilot "may be suffering long-term exposure to organophosphate chemicals" and that the pilot "may be suffering from some sort of chemical exposure in the BAe 146",[30] ,[31] 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.

Much of this information was again confirmed by leading medical experts at the 2005 BALPA conference on contaminated air which we co-sponsored. Despite the conference showing even more new data the CAA advised there was no new information presented and the data available was inconclusive and unsupported.[32] 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 Commons26 why the CAA had not contacted the specialists who were aware of the effects 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".

Furthermore, the Minister of Transport advised Paul Tyler MP on 9 February 2004 in the House of Commons11 that "The CAA is not aware of any adverse long-term health effects 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. 27, 26

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:

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:[34]

— 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?

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

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.[35] 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 effects of inhalation of the pyrolysis products of jet engine oils and hydraulic fluids has never been done. Research undertaken on the effects 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. OPIDN toxicity is not being described by crews. The toxicity which seems to be affecting crews is OPICN[36] 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.[37] It is well reported that inhalation exposure is more toxic than ingestion.[38]

Example—Misinformation and errors in the 2004 CAA Cabin Air Quality paper

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[39] 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 single 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—Proprietary Information, could definitely cause the symptoms reported by crews.[40] 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. This is not the case. The most toxic isomer of TCP is MOCP. The paper which was prepared by the DSTL[41] for the CAA completely ignores 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[42] at significantly higher quantities than TOCP and have been known for over 40 years to be 10 and five times more toxic than TOCP.[43]

Reliance on a BAe paper, subject to legal privilege and exempt from public disclosure,[44] 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.

Example—Inappropriate use of exposure standards

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.[45],[46] ,[47] ,[48] ,[49] ,[50] 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 comparison to the CAA efforts 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".41

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 staff do not know how to deal with these issues as they are specialist issues and yet the CAA has failed to offer any structured medical protocol or guidance to doctors, passengers or affected crews.

Example—Failure to ensure that passengers are informed when they have been exposed

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".[51]

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 acknowledge 100% certainty is not required to take preventative action

A CAA spokesperson stated for a media article that: "Before people say anything is harmful, it should be proven scientifically"[52] and that "There cannot be regulation on anything without scientific proof".[53] 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 difficulty".[54] 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 sufficient certitude"

or "The use of the precaution principle presupposes:

— the identification of potentially negative effects as a result of a phenomenon, a product or a process;

— a scientific risk evaluation which, owing to data insufficiency, of their non-conclusive character or their imprecision, doesn't allow the risk with a sufficient uncertainty."

Example—Misinforming the public

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".[55] This statement contrasts with the CAA statement in their 2004 Cabin Air Quality paper of "although some references are made concerning long-term health effects, 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 suffering from similar symptoms to those exhibited by flight crew".

The CAA advised the House of Lords in 2000 that it is focused on air safety 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.[56] 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

5 CAA-"The UK CAA is fairly unique in that it is funded entirely by the industry that it regulates and receives no government finance." Email from A Wallace, CAA Corporate Affairs-August, 2003. Back

6 Montgomery MR, Wier GT, Zieve FJ, Anders MW (1977) Human intoxication following inhalation exposure to synthetic jet lubricating oil. Clin Toxicol 11:423-426. Back

7 SAE (1981) Aerospace information report AIR 1539, 30/1/81, environmental control system contamination: sources of vaporous contamination. Society of Automotive Engineers, Warrendale, PA. Back

8 Mobil (24 January 1983) Internal correspondence from E Ladov: Mobil Jet Oil Corporation, Environmental Affairs and Toxicology Department, New York BAe Service Information Leaflet 21/27 28 September 1990. Back

9 BAe Service Information Leaflet 21/27 28 September, 1990. Back

10 "Aircraft Air Quality Malfunction Incidents: Design, Servicing, and Policy Measures to Decrease Frequency and Severity of Toxic Events"; D Best, S Michaelis, Air quality in airplane cabins and similar enclosed spaces; Publisher Springer-Verlag GmbH, August 2005. Back

11 Rolls Royce RB.211-72-7651 service bulletin, February, 1985. Back

12 Senate of Australia (2000) Air safety and cabin air quality in the BAe 146 aircraft. Senate Rural and Regional Affairs and Transport References Committee. Parliament of Australia. Final report, Canberra. Back

13 CASA and ATSB evidence to the Australian Senate Inquiry into Air Safety (1999-2000) BAe 146 Cabin Air Quality. Parliament of Australia, Canberra. 1 November 1999. Back

14 Hansard House of Commons 20 Oct 2004 : Column 682W. Back

15 Hansard House of Commons 9 Feb 2004 : Column 1234W. Back