Professor Michael Bagshaw, Dr Sarah MacKenzie Ross, Professor Helen Muir and Dr William Toff

10 JULY 2007

  Q140  Lord Sutherland of Houndwood: A comparison has been made with Gulf War veterans' illness, Gulf War syndrome as it is sometimes called and there was a US Research Advisory Committee on this that suggested a probable link between such exposures to neurotoxins and the development of Gulf War syndrome. Do you see any value in looking at a comparison of this kind?

  Dr MacKenzie Ross: Absolutely. I have come from looking at farmers who report ill health and the reason the pilots identified me as someone to be referred to is because one of the components of engine oil is an organophosphate and they felt that this might be the relevant neurotoxin. Certainly the profile that I have seen in the pilots is very similar to the profile of deficits seen in farmers, so comparisons of this nature would be useful. It is also important to look at how the pilots compare both with what we call healthy controls but also maybe with other pilots in the industry. At the moment, my understanding is that certain aircraft types appear to have more than usual numbers of fume events and what would be interesting would be to look at the profile of symptoms and deficits in pilots across different aircraft types.

  Q141  Lord Sutherland of Houndwood: You are specifying very interesting studies that might inform us. Is there a lot of research going on in this area? Is there any at all?

  Dr MacKenzie Ross: There is absolutely no research at all in the UK. In Australia there have been reports but, again, by clinicians of case series. There is a great need for research to be done in the UK. I believe the COT Committee will be making some recommendations in that area, but yes, we definitely need to do something.

  Professor Muir: We have not met until today, but I am actually leading a study for the Department for Transport in which we intend to do a very comprehensive study of the products which are emitted into the cabin. The study has only recently started but we have already had one intervention and we are halfway through a feasibility study. The UK is going to collect data on this subject.

  Q142  Lord Colwyn: If there is a fume event in the cockpit, is there automatically a similar fume event in the rest of the aircraft?

  Professor Muir: That is one of the things we will have to look for.

  Q143  Lord Sutherland of Houndwood: Have there been reports from passengers comparable to those from pilots?

  Dr MacKenzie Ross: There have been anecdotal reports. In America and in Australia quite a large number of reports have come from cabin crew. In the UK most of the reports appear to be coming from pilots at the moment but that may just reflect the fact that we have not done a survey of other groups. There have been passengers on particular flights where there have been problems who have reported persistent ill health following those flights.

  Q144  Lord Sutherland of Houndwood: This is a slightly broader question and others may want to come in on it, but are there practical preventative measures that could be taken?

  Dr MacKenzie Ross: My understanding is that the technology exists already that could resolve the problem, if the problem is proven to exist. For example, filters are available that could be put on aircraft. It is also possible to change the composition of the engine oil and I believe there are engine oils available with a slightly different composition. I am slightly getting out of my area of expertise but I have been led to believe that that might be an avenue worth pursuing.

  Q145  Lord Sutherland of Houndwood: You mentioned earlier on monitoring the quality of air in the respective cabins. I do not know whether any member of the panel wants to comment on whether that is being done or might be done more efficiently.

  Professor Muir: We are about to undertake a major exercise where we will monitor continuously throughout flights with the latest scientific equipment. One of the difficulties has been that until recently, there was not the equipment available which would be sufficiently sensitive to do this. We now have new technology available and this will be brought into this study. We shall be using more than one type of equipment.

  Dr MacKenzie Ross: The slight limitation is that fume events are quite hard to capture. You could in theory be monitoring aircraft and nothing happens. So obviously one issue is whether you capture a fume event or not. That is why some research needs to be done in parallel which is not dependent so much on monitoring; there ought to be some research just looking at pilots/aircrew/passengers versus other occupational groups versus healthy controls.

  Professor Bagshaw: When I was working for British Airways, it came to our notice that one of our aircraft types appeared to be responsible for a high proportion of fume events and British Airways contracted with BRE, an independent organisation, to come in to monitor a series of flights. Nothing abnormal was detected on this particular aircraft type, although there were no fume events during the monitoring programme. Just to answer your other question, if a fume event occurs, there is a drill for the pilots to breath 100% oxygen immediately and the 100% oxygen then excludes ambient cabin air being breathed. It is of interest that in two fume events of which I am aware, the pilots concerned reported that their symptoms got worse while they were breathing the 100% oxygen, which makes one wonder about the relationship between the cause and effect.

  Q146  Lord Sutherland of Houndwood: Clearly cause and effect are the key issues.

  Professor Bagshaw: Yes.

  Q147  Lord Howie of Troon: There is a certain amount of information available to passengers and general practitioners on fitness to fly. How do you assess that? Is there enough information available?

  Professor Bagshaw: There is a large amount of information available but, as we hinted at before when we were looking at risk factors with DVT, so much depends on awareness and on self-declaration of health. Following the report of your Committee in 2000, British Airways sent posters and information to every general practice in the United Kingdom, so a poster was available to give information about the health risks of flying. Many airlines developed their websites. I am not here representing British Airways I hasten to add, but in my time at British Airways we developed our health information on the website categorised into pre-flight, during flight and post-flight; but you can lead a horse to water, but cannot make it drink. My experience with lecturing to general practitioners is that there is an amazing ignorance amongst the medical profession about the health effects of flying and, frankly, I am not sure what else can be done. The Department for Transport is updating its information, the Department of Health is updating its "Yellow Book"—health information for overseas travel, all the airline websites have information, the Aerospace Medical Association does, et cetera. We have sent posters to GPs' surgeries. It is difficult to know what else can be done.

  Q148  Lord Howie of Troon: But do you think there has been an improvement since our last report?

  Professor Bagshaw: The number of in-flight medical incidents has not changed; that has remained constant.

  Q149  Lord Howie of Troon: Do you think there should be a comprehensive guide to GPs rather than posters and things of that sort?

  Professor Bagshaw: Yes, that information is available to them on websites. The Aerospace Medical Association has a very comprehensive guide, which is freely available to everybody.

  Q150  Lord Howie of Troon: I want to turn to the question of personal freedom. Travel by air is a personal choice obviously but do you think people could be prevented from flying because of their existing medical conditions?

  Professor Bagshaw: That does happen. There is pre-flight medical screening but, going back to my original point, you have to ask for it, you have to be aware of it. The major airlines will give advice. The check-in staff are trained to spot problems. If you turn up at check-in wheeling an oxygen cylinder it might be noticed, and certainly many airlines have the facility to get medical advice at the check-in stage and the cabin crew are conscious of assessing people's fitness to fly by looking at them. If someone has a lot of spots or is obviously short of breath, they may well question their fitness to fly. I do know that many airlines deny boarding and deny flight to people who appear unwell.

  Q151  Lord Howie of Troon: My last query. Earlier on we spoke about the problems of providing more legroom for big people. I can remember flying to Hong Kong in the company of an international rugby player who was very large indeed; a Scotsman as it happens. Could something be done like providing two seats without actually charging for two seats?

  Professor Muir: The airlines would find that very difficult because the airline that did that would be at a competitive disadvantage to other airlines that did not operate the same policy.

  Q152  Lord Howie of Troon: Yes, they might be at a competitive disadvantage but they would be providing customer service which should matter to some.

  Professor Muir: The problem is that many people do not wish to pay for customer service. You can have customer service in business and in first class but one of the lessons we have all learned from the low-cost airlines is that if it is cheap enough we do not mind having nothing to eat, nothing to drink and will stay there for a very long time. We do not even mind not having a pre-booked seat. It is becoming apparent to the whole industry that price is the determining factor in passenger choice.

  Q153  Lord Howie of Troon: I must say I do not really like paying for my drinks.

  Professor Muir: I do not think anybody does.

  Q154  Chairman: There is in fact at least one US airline I know of where you can, for the payment of £55, get five inches more legroom and that is a good idea. Do you think it would be a good idea to recommend that airlines provide such a capability?

  Professor Muir: One could recommend that airlines explored the possibility. The difficulty would be predicting how many people on any one flight would want the extra legroom and therefore how to design the passenger cabin.

  Q155  Baroness Finlay of Llandaff: On the ordinary flights, the emergency exit areas tend to have more legroom. How do you ensure that you actually do have fit people sitting in those seats who could open the emergency exit if needed, versus those who just particularly would like a bit more space to stretch out, but actually do not have either the upper limb strength or the right personality to cope in an emergency situation.

  Professor Muir: The check-in crew are trained to select people to sit in those seats who they believe could be suitable to open the exit, but I have to say it is a very difficult call because even if someone looks big enough to manage it, it is very difficult to say whether they are mentally robust enough to cope in an emergency. They are, in addition, approached when they sit in those seats by the cabin crew and asked whether they are prepared to open the exit in an emergency. I have to say it is a big ask of someone to open one of those doors. Most of the public do not realise what is physically involved and that they might be in the very difficult position of having to make the decision about whether it is safe to open it. When the captain calls over the PA, "Undo your seat belts and get out" or calls an evacuation, at that point those people have to look outside and assess whether there is a fire there or not and whether it is safe to open the exit. That is something cabin crew find difficult to do with training.

  Professor Bagshaw: It is interesting that you cannot pre-select an emergency exit seat if you check-in online, for that very reason. I would agree with Professor Muir that it is a very tricky situation.

  Q156  Chairman: In summary, Professor Muir, you would not think it reasonable to charge particularly tall people more for added legroom?

  Professor Muir: That is not a question I can answer. That would have to be a decision made by an airline. It would be company policy.

  Q157  Chairman: Could I return to the guide that GPs have and ask you, Dr Toff, whether all the different specialties, the cardiologists and orthopaedic and psychiatric experts, have been consulted on this guide?

  Dr Toff: I suspect Professor Bagshaw is better equipped to answer that but I believe it is likely that the specialist organisations such as the Aerospace Medical Association will have taken expert advice in preparing their own guidelines.

  Q158  Chairman: Do you want to comment Professor Bagshaw?

  Professor Bagshaw: The answer is yes. Certainly the Aerospace Medical Association took a year to revise its guidelines because they took advice from all the specialties. IATA, the International Air Transport Association, publishes similar guidelines and, again, they have taken specialist advice, so I can reassure you on that.

  Q159  Baroness Finlay of Llandaff: I slightly play devil's advocate. The general practitioner is trying to help patients assess risk and interpret risk and I do wonder whether it is almost inappropriate to be aiming the filtering points at the GPs who are actually also acting as the patients' advocate. At the end of the day there are lifestyle choices. The GP does not help them select which beds they sleep on even though they have bad backs, does not help them select what type of kitchen furniture they have despite disability, or whatever. I just wonder whether it is really extending the role of the GP beyond the role that they ought to have and imposing an unrealistic expectation that they could somehow be a gatekeeper on those who have an illness of some sort or a risk of some sort. Actually, if they know that is their risk, then it is up to them to take it, if they want to. The problem is that people do not understand risk and they think that somehow there should be zero risk and there is no such thing as zero risk.

  Professor Bagshaw: Absolutely. It is fair to say that there is no expectation that the GPs are acting as the filter. It is giving the GPs the information to allow them to advise the patients who can then make their choice. If we go a stage further, most of the airlines do provide some form of medical filter, whether they employ medical advisers direct or whether they subscribe to a provider such as MedAire or International SOS who can provide pre-flight clearance and pre-flight information. I was a GP for a short time and I know the problem and I can reassure you that there is no expectation that the GPs make the decision.