Memorandum by Ms Christine Standing MA
FLYING IN
THE FACE
OF SCIENCE:
HUMAN FACTORS
CONSIDERATIONS IN
THE CABIN
ENVIRONMENT
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
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 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 processto 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 DeathsA 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:
systematically reviewed;
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;
Findings
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 bereavedexcept
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 flimsyit 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.
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 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.
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 TO
CABIN SERVICE
PROCEDURES
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;
(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 healthpilot
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 "Commercialin 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]
COMMENT
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.
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
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 COTthe 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]
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;
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 FINAL WORDTHE
TOMBSTONE IMPERATIVE
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.
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 Zealandthat 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 familiesthe
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 victimsthe Tombstone Imperative;
UK Airline Pilots' mortality/morbiditywhat
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 outcomesones
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).
RECOMMENDATIONS
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
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