Select Committee on Science and Technology Written Evidence

Memorandum by Ms Christine Standing MA


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.


  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 effects 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 effects of air travel; and changes to Cabin Service 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, 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."[88] This is not to condone an informal approach to safety; there is no room for an ad hoc, informal approach.

  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".[89]

  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 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."[90]

  Investigators: "When we seek to 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."[91] 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 traffic controllers, maintenance personnel and others. This can happen when the investigator 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."[92]

  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.)

  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 effectiveness of the system and the well-being of the individuals concerned."[93]

  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 differing in any particular respect from those established by an international standard, shall give immediate notification to the International Civil Aviation Organization of the differences between its own practice and that established by the international standard." Where amendments to standards are not complied with that State shall 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 difference which exists between one or more features of an international standard and the corresponding national practice of that State."[94]

  Work-Related Deaths—A Protocol for Liaison:[95] The purpose of the protocol is to ensure effective liaison between different 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 difficult 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 effects 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 account 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.[96]

  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; I think we destroyed him."[97] Recent research findings had been cited in these letters, one referring to possible deaths from the effects of 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".[98] The airline response was brief, "I can't agree"—a personal response with no scientific evidence or consideration to support this view.[99]

  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.


  These reports were not shown to the author. However, the airline report considered that concerns "had been subject to a thorough investigation. These concerns were found to be unsubstantiated in all cases."[100]

  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.[101] 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 insufficient.

  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.

  Research indicates that "systems that have not responded to the deficiencies raised in normal accidents have been doomed to repeat them."[102] In organisational safety, managerial levels are at least as important as technical failure and human error in causing accidents.[103] Safety on board aircraft is dependent on Human Factors systems[104] and Flight Deck confusion is cited in many aviation incident reports.[105]

  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 be 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 ineffectual."[106]

  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."[107]

CAA Response

  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,[108] 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.

CAA Response to utilise "Work-Related Deaths: A Protocol"

  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.[109] The reason given for this refusal to use the Protocol on Work-Related Deaths 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.[110]

  Significantly, two senior aviation medical personnel consider, and have offered 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 officially 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.


  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.


  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 have 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..."[111] The conclusion must be that this leaves airlines with a free hand to ignore health and safety briefings for aircraft that are airborne.


    —    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.


  This section, "cabin service procedures" relates to how flight deck and cabin crew work together in the operating environment in order to maintain safety.[112] It is in two parts, the first regarding human factors, and the second relates to the physical environment. The reason for the inclusion of these together is systemic: the effects of stress are cumulative and include physical, mental and emotional factors.[113] Further physical stressors have been reported regarding toxic effects of chemicals on aircrew, leading to pilot incapacitation.[114] 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 emotional stress resulting in an acute alarm reaction."[115] More recent work has confirmed these early findings.[116]

  Clearly, "stress management is an important part of Crew Resource Management because it affects the operational effectiveness of the team... Under no circumstances should either excessive workload or excessive stress jeopardise the safety of a flight."[117]

Cabin Environment. Human Factors

  The above Case Example includes scientific evidence from psychological and human factors research. 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.[118]

  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.

  Cabin Services are reliant on procedures such as recruitment, training, and accountability of suitable staff. Research also demonstrates that organisational factors, how the airline organises their departments and how departments relate to each other, also effects safety in the working environment.[119]

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.

  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."[120]

  1999, February: Organophosphate lubricants were the focus of a question regarding "possible health hazards for air crews [66599].

  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."[121]

  2001 March: the cockpit of a British Aerospace 146 filled with toxic fumes. A sudden and unexpected Airworthiness Directive was issued. Close inspection of this reveals a vague reference to a previously unreported "recent crew incapacitation 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.[122]

  2001: Aerotoxic Syndrome Identified.[123] 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 difficulties (shortness of breath), tightness in chest, respiratory failure requiring oxygen;

    —    cardiovascular symptoms: increased heart rate and palpitations;

    —    irritation of eyes, nose and upper airways.[124]

  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 effect of cabin air contamination on the pilot's ability to safely fly and land an aircraft." (ie not infants or crew).

  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."[125]

  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 is 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."[126]


  This is not a comprehensive list; it represents key milestones in the history of cabin air incidents.[127]

  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.


    —    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 clinical 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 different decision. That is not being impartial."[128]

Conflicts of Interest?

  The Countess of Mar has highlighted how "the Government in its attempt to bury this issue (of 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 differing view to that held by the Royal Commission."[129] He is also a member of COT—the Committee on Toxicity.

  "Confidential documents disclose that former Environment Minister Michael Meacher and Food and Farming Minister 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."[130]

  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 decrees 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"—[Official Report, 24 June 1997; col 1558-9.]".[131]

  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:

    "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 suffered memory loss and difficulties in retrieving words."[132]

  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."[133]


  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;

    —    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;[134]

    —    Slow Government responses.

  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." [135]


  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 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."[136] This sounds familiar to UK ears with its self-regulation.

  "Airplanes and helicopters crash, crew members and passengers are killed, horrendous liability and damage litigation and unbelievable grief and suffering continues because, for whatever reason, there is still insufficient feedback, open exchange of technical information on a worldwide basis, thorough investigation of seemingly minor operational occurrences or mechanical anomalies."[137]

  The term, "The Tombstone Imperative", was used originally as a chapter heading quoting Barry Sweedler, one of the senior officials of the National Transportation Safety Board, which supervises aircraft safety in the USA. He is recorded as saying, "We regulate by counting tombstones." It reflects 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."[138]

  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.


  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 suffering 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 effect:

    —  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).


Safety Research in Human Factors

  On the questions about "More research into the health effects 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.

    —    "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."[139]

    —    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

88   Human Factors Digest No 7. circular 240-AN/144. Back

89   Human Factors Digest No 7. circular 240-AN/144 para 1.27. Back

90   Human Factors Digest No 7. circular 240-AN/144. 1.28. Back

91   Hawkins, Frank H, (Captain) (1989) Educating the Educators in Human Factors. Vol 36.No 2. March/April 1989 Flight Safety Foundation. Back

92   Human Factors Digest No 7. circular 240-AN/144.). Back

93   Hawkins, Frank H, (Captain) (1989) Human Factors and Medicine: Clearing up some Confusion. Human Factors and Aviation Medicine. Vol 36. No 1. January/February 1989 Flight Safety Foundation. Back

94ð_ñ9ed.pdf Back

95   Work-Related Deaths. A Protocol for liaison: Back

96   Standing, C (2004) "Civil Aviation; Civil War?" Report prepared for the Centre for Corporate Accountability. Back

97   Letter: Command Training (ICUS) 1 October 1996. Back

98   Stansfield, Stephen, Head, Jenny and Marmot, Michael (2000) The Whitehall II Study. Work related factors and ill health. Contract Research Report 266/2000,Crown copyright 2000. Back

99   Letter from airline to P A Standing. Undated. Back

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104   ICAO. Back

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107   At a Plenary meeting of the Aviation Study Group, Linacre College, Oxford. 16 February 2001. Back

108   See The Countess of Mar moved Amendment No 35: 8 December 2005; The author obtained the names of these researchers through the Freedom of Information Act. Back

109   Letter dated 16 April 2003. Neil Masters. Senior Policy Advisor. CPS. Back

110   Letter 27 June 2003 to Dunwoody, copied to T Walker. Director General. Back

111   Henderson, Graeme. (2002) Enforcement of Health and Safety on Aircraft. Health and Safety Commission. HSC/02/54. Back

112   Edwards. M, (1992) Crew Co-ordination Problems Persist, Demand New Training Challenges. Flight Safety Foundation. Cabin Crew Safety. Vol 27 No 6. November/December 1992. Flight Safety Foundation. Back

113   Selye 2000. Back

114   Standing, C (2005) The Aviation Safety System. Political, Organizational and Personal. Appendix 39 in The Work of the Civil Aviation Authority Thirteenth Report of Session 2005-06. House of Commons Transport Committee, The Stationery Office. Back

115   Selye 1984:212. Back

116   Nishiyama, Katsuo, and Jeffrey V Johnson (1997) Karoshi-Death from overwork: Occupational health consequences of the Japanese production management (Sixth Draft for International Journal of Health Services) 4 February 1997. Back

117   Orlady. H W (1999) Human Factors in Multi-Crew Flight Operations. Ashgate. :281-282. Back

118 Back

119   Chute, Rebecca D and Wiener, Earl L, (1994) Cockpit and Cabin Crews: Do Conflicting Mandates Put Them On a Collision Course? Cabin Crew Safety. Vol 29. No 2. March/April 1994. Flight Safety Foundation. Back

120   Montgomery, Mark R, Wier, Thomas G, Zieve, Franklin J, Anders, MW, (1977) Human intoxication Following Inhalation Exposure to Synthetic Jet Lubricating Oil. Clinical Toxicology 11(4), p 423-426) Back

121   Holding answer 19 January 1999] (Hansard). Back

122 Back

123   Winder, C and J C Balouet (2001) Aircrew exposure to chemicals in aircraft: Symptoms of irritation and toxicity The Journal of Occupational Health & Safety-Australia and New Zealand, Vol 17, October 2001. Back

124   This list appears at Back

125   Hansard, House of Lords. 8 December 2005 : Column GC133 Lady Mar. Back

126   Hansard, House of Lords. Aviation: Air Quality: Column WA215 Lady Mar. Back

127   For a comprehensive list see Michaelis, S, (2007), Aviation Contaminated Air Reference Manual. Back

128   Hansard, House of Lords. 27 June 1997 at Column 1559. Lady Mar. Back

129   Hansard, House of Lords. 8 December 2005: Column GC133 Lady Mar. Back

130   Antony Barnett and Mark Townsend Sunday July 13, 2003. The ObserverBack

131   Hansard, House of Lords. 8 December 2005: Column GC133. Lady Mar. Back

132 Back

133   ibid. Back

134   This is the case of pilot incapacitation mentioned in Standing (2006). Back

135   The Work of the Civil Aviation Authority; Thirteenth Report. House of Commons Transport Committee para 39. p 16). Back

136   Weir, Andrew (2000) The Tombstone Imperative. Simon and Schuster:252. Back

137   Rudy Kapustin in Weir 2000: 264. Back

138   Weir 2000:1. Back

139   Hansard, House of Lords. 8 December 2005: Column GC136 Lady Mar. Back

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