Select Committee on Science and Technology Written Evidence

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 effects 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 effects and similarly no longer able to fly in most cases. I am also aware of the same effects 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.

  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.[70] 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 effects of chronic neurotoxic effects 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 effects experienced. 138 (57%) pilots of the 242 respondents reported adverse effects ranging from short through to long term effects (one deceased). Of these 82 (34%) reported short term adverse effects only, while 61 (25%) advised medium to long term symptoms, most likely in addition to short term effects. 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 effects and exposure background. Several other pilots reported having to take between several months to a year off work to recover from adverse effects. 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 off 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 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

  The 2000 Lords report failed to highlight the wealth of data confirming ill effects in crews and passengers exposed which has existed for over 30 years.[71] Crews around the world are showing a remarkable similarity in symptoms experienced.

  The health effects being reported and diagnosed by medical doctors and other experts show a very strong pattern and are supported by physical evidence. Medical effects being seen in crews include but are not limited to: respiratory damage, CNS and PNS problems, autonomic nervous system and neurological damage, neuropsychological effects, immune system effects, reproductive problems, genetic problems, fatigue and many more. Reports of Parkinson's, MS, ME were also being reported 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,[72] ,[73] and a 2005 Contaminated Air Conference in London[74] have confirmed that crews and passengers are suffering both short and long term medical effects 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 suffering from similar symptoms to those exhibited by flight crew."

  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.[75],[76] 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 effects 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 effects of exposure have been accepted as real and genuine


  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 effects 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 effect 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.


  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 effects or adverse symptoms.


  The 2000 Lords report mentions the medical effect 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 effects 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 deliberately 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.[77],[78] 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.


  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 are owed a duty of care to be informed of the potential problem of contaminated air, when they are exposed and offered 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 the 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. 67 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 effects 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 effectively 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.

  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.[79],[80]

    "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

70   Michaelis S, (2007) Aviation Contaminated Air Reference Manual. ISBN 978-0-9555437-0-8. Back

71   Montgomery, M R, Wier, G T, Zieve, F J, Anders, M W Human Intoxication Following Inhalation Exposure to Synthetic Jet Lubricating Oil. Clinical Toxicology 1977; 11: 423-426. Back

72   Winder, C, Michaelis, S, (2005). Aircraft Air Quality Malfunction Incidents: Crew Effects from Toxic Exposures on Aircraft. Air Quality In Airplane Cabins And Similar Enclosed Spaces-The Handbook of Environmental Chemistry-Publisher: Springer-Verlag Gmbh. August 2005. Back

73   Winder, C, Fonteyn, P, Balouet, J ¸C. (2002) Aerotoxic Syndrome: A Descriptive Epidemiological Survey Of Aircrew Exposed To In-Cabin Airborne Contaminants. Journal Of Occupational Health and Safety-Australia And New Zealand 18: 321-338, 2002. Back

74   Contaminated Air Protection: Proceedings of the Air. Editor: Chris Winder. Publisher: School of Safety Science, University of New South Wales, Sydney NSW 2052, Australia, August 2005. ISBN: 0-7334-2282-9. Back

75   Nicholas, J S, Lackland, D T et al "Mortality among US commercial pilots and navigators" Journal of Occupational and Environmental Medicine, Volume 40(11) November 1998 p 980-985. Back

76   Nicholas J S, Butler G C, Lackland D T et al (2001) Health among commercial airline pilots. Aviat Space Environ Med: 72:821-6. Back

77   Michaelis, S, (2003), A survey of health symptoms in BALPA Boeing 757 pilots, Journal of Occupational Health and Safety, Australia and New Zealand 19: 253-261, 2003. Back

78   Dr Bhupi Singh (2004) Australia Aviation Safety Spotlight 0304: In flight smoke and fumes. Senior Research Officer, AVMED, RAAF Edinburgh, SA, 2004. Back

79   AOPIS DVD: "Contaminated Air: An ongoing Health and Safety issue" Comment by Reverend J Woodley. Back

80   Woodley Reverend J, The Politics Of Aircraft Health And Safety Senate Inquiry, Australian Parliament October 2000. BALPA, UNSW. Proceedings of the BALPA Contaminated Air Protection Air Safety and Cabin Air Quality International Aero Industry Conference, held at Imperial College, London, 20-21 April 2005: ISBN 0-7334-2282-9. Back

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