| Recommendation |
Government response |
Update |
| A Higher Profile for Health |
| |
| 1.8 We recommend the Government to ensure that concern for passenger and crew health becomes a firm priority.
(Paragraph 8.9)
| The study into "Possible Effects on Health of Aircraft Cabin Environments" is designed to reveal the main areas of concern, and to identify where there are significant gaps in the existing knowledge base, with a view to promoting or facilitating further, well-targeted research.
| As part of the Government response to the HoL inquiry, DFT, DH, HSE and CAA jointly commissioned a stage 1 study into the ` Possible Effects on Health of Aircraft Cabin Environments'. This study was carried out by the Institute of Environmental Health and published in January 2001.
|
| The Government proposes to establish a standing inter-departmental Aviation Health Working Group (AHWG), chaired by DETR, which will meet on a regular basis.
| Stage 2 of the study was carried out by BRE and was submitted to the AHWG for consideration in July 2001. The study investigated the state of knowledge of issues identified in the Stage 1 study, and devised a priority assessment of research areas. The study identified 5 areas for future research—
DVT
Cabin Air Quality
Transmission of infection
Cosmic Radiation
Jet lag
|
| | The Aviation Health Working Group first met on 26 March 2001 with members from DFT, DH, CAA and HSE. Representatives from the aviation industry, consumer groups and other interested parties such as medical specialists also participate in meetings.
|
| | The Aviation Health Unit (AHU), which acts as a focal point for aviation health issues in the UK, was established on 1 December 2003 in the CAA. The Unit is the primary source of advice to DFT, DH and industry. The Head of AHU is Dr Raymond Johnston.
|
| | In the Civil Aviation Act 2006, the Secretary of State for Transport is charged with "the general duty of organising, carrying out and encouraging measures for safeguarding the health of persons on board aircraft". The functions of the CAA as set out in section 3(c) of the Civil Aviation Act 1982 are also amended to include the health of persons on board aircraft.
|
| 1.9 We recommend the Government actively to pursue the strong UK interest in passenger and crew health through its international contacts with the Joint Aviation Authorities (JAA), the International Civil Aviation Organisation (ICAO) and other appropriate organisations, and we urge them all actively to promote health. (Paragraph 8.10)
| The Government shall continue to work with like-minded countries to try to ensure that health issues are on the international aviation agenda. DETR has proposed that the European Civil Aviation Conference (ECAC) consider submitting a paper on air travel and health at the ICAO Assembly in autumn 2001.
| DFT and CAA continue to look for opportunities to work internationally and within Europe on suitable issues. An example is the EU-led Ideal Cabin Environment (ICE) Project, which is looking into the combined multiple effects of long-haul travel at varying cabin altitudes on people of different ages. This project is co-ordinated by BRE. The medical chair for the project is Dr Raymond Johnston, Head of the AHU.
|
| The CAA has initiated a research project to cross-reference medical records held by the Division on aircrew to the types of flying undertaken during the pilot's lifetime. These will then be compared to the subject's subsequent medical history obtained from death certificates and other sources. This should provide information about possible links between the aircraft cabin environment and subsequent disease.
| |
| In 2001, DFT presented a paper to ECAC on Aviation Health which led to the formation of a working group on Air Passenger Health Issues (APHI). The aim of the working group was to produce an ECAC manual of best practice, which was submitted to ICAO Assembly in the form of an information paper in 2004. The Manual covers services to passengers (on-board medical kit, crew training, airport facilities and cabin design); passenger information; and medical incident reporting. Work was also carried out on how to introduce legal protection for volunteering health professionals (Good Samaritan Law versus insurance cover provided by the airlines). Dr Annette Ruge represented the UK at recent meetings.
| |
| 1.10 We recommend the United Kingdom and other governments to do everything they can to reduce inertia within the international safety-focused regulatory structures. (Paragraph 8.7)
| The Government is not complacent about levels of performance in ICAO or JAA, and over recent years has been in the forefront of moves in both organisations to improve administrative efficiency and combat inertia. But negotiations establishing international regulations are by their very nature complex, requiring flexibility and willingness to unite often disparate views, which can mean that progress is not as rapid as might be achieved within a national administration.
| See responses to 1.8 and 1.9.
The Department for Transport and the CAA have arranged to visit the European Aviation Safety Agency (EASA), the successor body to the JAA, in the Autumn to brief officials on progress in the UK across health issues, especially in relation to cabin air research.
|
| 1.11 We were surprised at the lack of attention—by regulators, airlines and aircrew trade unions—to the health of aircrew. We are aware that there are serious issues of medical confidentiality and job security involved. Nevertheless, we recommend that the present rules, agreements and attitudes regarding the monitoring and recording of the general health of aircrew, over and above their fitness to operate, should be reconsidered urgently (Paragraph 3.48).
| Council Directive 2000/79/EC, which provides for a European Agreement on the Organisation of Working Time of Mobile Workers in Civil Aviation, has recently been adopted following agreement between the European social partners. The Government is currently considering the implementation of this Directive, which should bring about improvements in the monitoring and recording of the general health of aircrew.
| On 13 April 2004 the Civil Aviation (Working Time) Regulations 2004 came into force, transposing the provisions of Council Directive 2000/79/EC on the organisation of working time of mobile workers in civil aviation into UK legislation (see also 1.38).
At the same time DFT set up the Aviation Occupational Health and Safety Working Group to look at certain aspects of crew health and safety in the cabin environment. The group is chaired by the CAA, with membership drawn from both the airlines and employees representatives, and has been instrumental in producing guidance material for aircraft operators and others involved in the operation of aircraft, on good health and safety practice in the cabin. Employer representatives on the working group have welcomed its work as having raised the profile of health and safety issues within their organisations.
|
| 1.12 In the case of pilots, we recommend that, if the authorised medical examiner (AME) finds evidence of significant ill health not necessarily affecting a pilot's fitness certification, this should be recorded and reported both to the CAA and to the affected person's general practitioner. (Paragraph 3.48)
| In the CAA's view it is unlikely that an AME would find significant ill health in a pilot which would not affect their medical certification. If a pilot needs treatment or advice about a condition they are invariably referred back to their own general practitioner who can, if necessary, have them seen by a specialist. If a pilot is unfit to fly then he or she has a legal duty to inform the CAA's Medical Department.
| Under the Air Navigation Order flight crew have an obligation to inform the CAA of personal injury, illness involving incapacity for 21 days or more or pregnancy. In order to capture all relevant health information so that appropriate advice can be offered to flight crew, the reverse side of the medical certificate has been printed with detailed information advising them that they should consult the CAA or their Aviation Medical Examiner if aware of a decrease in medical fitness. An Aeronautical Circular has also been issued further expanding this information and giving examples of medical events and illnesses that should be reported
|
| Fitness to fly | |
|
| 1.13 The booklets from the Department of Health (DH), Health Advice for Travellers, and from the Air Transport Users Council (AUC), Flight Plan, should be important sources of health information and advice for intending passengers. We recommend that priority be given to refining the advice in Flight Plan: "If you have any concerns about your fitness to fly, talk to your doctor before you book your flight", which needs to be made much more specific (Paragraph 8.48).
| The AUC has informed the Government of its intention to publish an up-dated version of Flight Plan incorporating, inter alia, an expanded section on health issues. The Government proposes to produce a standard form of words giving advice on the major health risks associated with air travel. This advice, tailored as appropriate, will be included in both Health Advice for Travellers and Flight Plan and will be referred to in Travelling Safely, a booklet issued by the CAA. It will also be made available to airlines and other parties wishing to give information on air travel and health, including representative bodies of tour operators.
| The AHWG worked with DH to agree text subsequently issued as official Government advice. This was circulated to airlines and other travel interests in 2001 and was placed on NHS Direct and the DH website (on 30 November 2001).
Since 2001 the internet has developed as the main method of transmitting advice to travellers. DH has two current articles containing information and advice about DVT on its website: a section in Health Advice for Travellers: http://www.dh.gov.uk/en/Publicationsandstatistics/
Publications/PublicationsPolicy
AndGuidance/DH_4123441 and a more detailed document called Advice on travel-related DVT which was last updated in March 2007. http://www.dh.gov.uk/en/Policyandguidance/
Healthandsocialcaretopics/Bloodsafety/
VenousThromboembolismVTE/DVT/DH_4123480
|
| | The Health Protection Agency website has links to other government and non-government websites containing travel advice
http://www.hpa.org.uk/infections/
topics_az/travel/travel_advice.htm
It also works in partnership with the National Travel Network and Centre (NaTHNaC) which is funded by DH. NaTHNaC produces information sheets on DVT for travellers and for professionals. http://www.nathnac.org/yellow_book/13.htm.
|
| | Likewise Health Protection Scotland has a website called "Fit for Travel' which includes information and advice about air travel http://www.fitfortravel.nhs.uk/advice/index.htm
|
| | The FCO website www.fco.gov.uk has a section promoting its Know before you go travel safety campaign including the advice to visit your GP for vaccinations at least six weeks before travelling overseas.
|
| | http://www.fco.gov.uk/servlet/
Front?pagename=OpenMarket/
Xcelerate/
ShowPage&c=Page&cid=1007029391116
|
| | The CAA produces a Travelling Safely leaflet for passengers which is available via the CAA website.
|
| 1.14 We recommend CAA to revise its Travelling Safely leaflet, at least to cross-refer to the revised Health Advice for Travellers and Flight Plan.
We also recommend DH, CAA and AUC to consider whether the combination of their three publications as currently conceived best serves the travelling public's information needs (Paragraph 8.49)
| The CAA agrees that the inclusion of references to Health Advice for Travellers and Flight Plan (as revised) within the Authority's Travelling Safely leaflet would be a helpful step.
In the light of the study that the Government has commissioned into cabin health, the AHWG will examine the current range of publications and will consider the possibility of commissioning a further study to advise on how effective information on air travel and health can be best conveyed.
| The Travelling Safely leaflet includes the website addresses for health advice from DH and FCO.
The AHU has its own website, providing a focal point for enquiries about aviation health issues and featuring FAQs and pertinent health links. There were approximately 1200 "hits" in May 2007.
|
| 1.15 We recommend that DH monitor the use of the revised Health Information for Overseas Travel to ensure that, with further additions and amendments as necessary, the publication provides the user-friendly authoritative information source that is needed by health professionals (Paragraph 8.41)
| This book was initially intended to cover disease risk—mainly related to infection—in destinations abroad. It has since been expanded to cover "the traveller" as well as "the destination" in more detail. The book, which is issued to all General Practitioners and practice nurses, is in the process of being revised by the Department of Health.
| Information for professionals can be accessed at the NaTHNaC website.
http://www.nathnac.org/yellow—book/13.htm.
NaTHNaC are funded by DH to provide travel health advice. NaTHNaC took over the Health Information for Overseas Travel, also referred to as the Yellow Book, and it is now on its website. The Yellow book has been updated in a number of ways since the first edition in October 2001. New chapters have been added, including "Medical considerations for the journey" which includes a section on DVT.
|
| Deep Vein Thrombosis |
| |
| 1.16 It is imperative that the current paucity of data on deep vein thrombosis (DVT) be remedied and we recommend that an epidemiological research programme of the case-control type be commissioned by DH as soon as practicable (Paragraph 6.25).
| The Government shares the view given in the evidence to the Inquiry that of the three major options of study methodology for looking further at the issue of DVT, the proposed case-control study is likely to be the only one that is feasible. However, even a study of this type is likely to be large and expensive. Before embarking on a study on such a scale we consider that a systematic review of the literature is required, to determine fully the work that has already been carried out, and to identify the gaps for further research.
| The UK and the European Commission funded a World Health Organisation (WHO) research programme costing €2.8million (to which the UK contributed €1.8million from DFT and DH funds) to look at the incidence and mechanisms of DVT. Known as the WRIGHT project, the results of this two-year study showed that long-distance travel leads to a small but increased risk of DVT. The risk, which applies to all forms of travel, appears to be predominantly the result of prolonged immobility. A summary of results was published on the DFT website in December 2005, together with a Press Release—attached at Annex B—to promote understanding of the nature of the risk and higher risk groups. DH updated its web advice to reflect the findings. The WRIGHT phase 1 report is due to be published by the WHO on 28 June 2007. The WRIGHT team are seeking funding for a second phase of the study, to look at interventions. The UK would be sympathetic to contributing but the scale of study needed is likely to need international funding.
|
| | DH and BATA (British Air Transport Association) commissioned Research Works Limited to conduct a study to assess effectiveness of publicity on DVT. The findings presented on 15 October 2003 showed most people were aware but depth of knowledge varied. Health messages were subsequently reviewed and revised where necessary.
|
| | One output of the study was about the use of aspirin which DH followed up in a study aimed at quantifying the aspirin usage amongst UK long-haul aircraft passengers. The "Synovate" report was published on DFT and DH websites in April 2006.
|
| 1.17 As an interim measure pending the development of more authoritative guidance, we recommend airlines, their agents and others with consumer interests to repackage the summary indicative and precautionary advice on DVT in Box 4, together with the summary information on predisposing and risk factors in Boxes 2 and 3, and make it widely available to the general public. This will enable those who have no access to other advice to make preliminary decisions about their travel and the risk of DVT (Paragraph 6.29).
| Although it is for others to respond to this recommendation, the Government accepts all the boxes contained in the Report as useful interim guidance, pending further evidence. The Government endorses the guidance in Boxes 2 and 3 (pages 46 and 48 of the Report), subject to some rearrangement to give an indication of relative priorities.
The interim precautionary and preventative advice concerning air travel and DVT, as presented in Box 4, is helpful. However, for those considered as "substantial risk", DH recommends that medical advice should be obtained.
| Airlines provide information to passengers on their long haul flights through websites, and in-flight magazines and/or films.
Information is also available from a variety of sources eg supermarket magazines.
|
| Many airlines had taken steps to enhance the information made available to passengers prior to publication of the recommendations. All BATA member airlines are now compliant with the recommendations with regard to DVT; many also provide extensive information on a range of travel health issues.
| |
| 1.18 We recommend the Government to consider tackling DVT on a wider travel-related front or, indeed, as a general public health matter (Paragraph 6.30).
| The WHO research programme referred to above should make a significant contribution towards clarifying the prevalence of DVT. Should the outcome of research reveal an increased likelihood of DVT from a wide range of transport modes, or that the condition is so widespread that it requires action as a general health matter, then such action will be considered.
| The Chief Medical Officer has recently (April 2007) published a report on the prevention of VTE in hospitalised patients (Report of the independent expert working group on the prevention of venous thromboembolism (VTE) in hospitalised patients). The expert working group Ministers asked to be set up and report to CMO on the subject took the opportunity to consider VTE in the wider context, including travel. The report is available on line http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/
PublicationsPolicyAndGuidance/DH—073944
|
| 1.19 The term "economy-class syndrome", widely used to refer to flight-related DVT, is misconceived in suggesting that the possibility of DVT need not concern business and first class air travellers—or those using other forms of long-distance transport. We recommend that health professionals and others stop using the seriously misleading term "economy-class syndrome". "Flight-related DVT" or "traveller's thrombosis" would be more appropriate (Paragraph 6.23).
| Although this recommendation is not addressed to the Government, we fully agree that this misleading term should not be used in relation to flight-related DVT. DH is currently discussing how best to circulate this message to health professionals.
| In Ministerial statements and Government published material, we do not use the term "economy-class syndrome", and take appropriate opportunities to advise against it.
|
1.20 In relation to air travel, and applying the precautionary principle used in other fields where health risks are considered possible but are not well defined or quantified, there are measures which could be taken to improve information and alleviate concerns about flying and DVT, and to encourage preventative activities. We recommend that airlines and their associates reappraise their current practices in relation to not only the provision of information for passengers but also the design of the cabin and cabin service procedures. We also recommend the Government, aviation regulators, trade groups and consumer representatives to consider what action they should take in relation to these points (Paragraph 6.31 and 6.32)
| The Government agrees that encouraging passengers to avoid prolonged immobility is a key factor in any strategy to reduce the risks of DVT. But the Government is conscious of the need to word any new instructions carefully, so that passengers who spend more time out of their seats as a result of the instructions are not exposed to unnecessary risk from injuries associated with unexpected movement of the aircraft.
| In-flight information for long-haul passengers is now commonly provided by airlines.
|
Seating |
| |
| 1.21 We were pleased to hear about new CAA research into people's size and the reduction in mobility after long flights to ensure that the emergency evacuation requirements are in line with modern circumstances. Given changes over the years in the length of flights and in the sizes, ages and health states of people undertaking them, we recommend that this research be completed urgently (paragraph 3.51).
| The CAA-funded research study, on behalf of the JAA, is considering the relationship between aircraft seat dimensions and passenger sizes. The work looks at the changing size of the European population but also includes a review of recent DVT research.
EASA's draft rule making programme for 2005-2007 recognises that the issue of seat spacing needs to be investigated.
| The research report EC1279 "Anthropometric Study to Update Minimum Aircraft Seating Standards", prepared by ICE Ergonomics for the Joint Aviation Authorities (JAA), was published in July 2001. The recommendations in the research report, specifically the proposals for new minimum dimensions between seats, were presented to the JAA Cabin Safety Steering Group at the time of the publication of the report. The increased dimensions compared to the existing UK requirements would require modification of aircraft with significant commercial implications for affected operators. Implementation would therefore be necessary on at least a Europe wide basis. EASA has since assumed responsibility for large aircraft certification and rulemaking.
|
| | At the advent of EASA the UK used the provisions of Regulation (EC) 1592/2002 Article 10 (1) to maintain the UK seat spacing standards as a unique, mandatory requirement in the UK. This Article provides for a Member State to react to a safety problem, if that problem is the result of an inadequate level of safety resulting from application of the Regulation. This action caused EASA to consider seriously the issue of seat spacing standards. After deliberation EASA concluded that the issue was not one of airworthiness, but of operations and instructed the CAA to remove the Article 10 (1) item and replace it with an operating rule. This was done and is recorded as Civil Aviation Publication CAP 747, Generic Requirement No. 2, thereby allowing CAA to apply its previous seat spacing standards.
|
| | Although the seat-spacing issue is not currently on the EASA rulemaking programme, it will need to be addressed by EASA once it assumes responsibilities for regulation of operations, expected in early 2008.
|
| | Although there was originally an intent to include consideration of the effects of long flights on mobility (ability to leave the seat and move to the aisle), this was not included in the completed phase of the research. It would need to be included in any future research update to support new rulemaking.
|
| | Airline seat-pitch data is commonly available online and should be available from airlines on request.
|
| 1.22 To facilitate passengers' choice of seating, we recommend CAA to use its current research to develop an unambiguous set of definitions for seat dimensions. The key issues are: the minimum size of seat taking account of health considerations; accommodation of passengers above average size; and proper allowance for seat-space reductions from the seat in front being reclined, material in seat-back pockets and fold-down tables (Paragraph 6.49)
| The CAA-funded research study (and any subsequent follow-on study) will provide Government with the information necessary to review current regulations on seat spacing. In the light of the study DETR and the CAA will also consider the scope for developing unambiguous definitions for seat dimensions for use in informing passengers of the seat size and space available on a flight.
| See item 1.21 |
Ventilation |
| |
1.23 For the main purpose of airworthiness certification, JAA currently has no specific cabin air supply requirements for passengers, and the US Federal Aviation Administration (FAA) requirement is seen by manufacturers as, in some cases, impossible or impracticable. Because of the intrinsic importance of the matter and also to clarify matters which cause great public concern, we recommend the Government, CAA and JAA to find a practicable way forward as soon as possible (Paragraph 3.36).
| The Government accepts this recommendation. The CAA will write to the JAA requesting a review of airworthiness requirements and guidance material relating to cabin air supply requirements for passengers.
See also the Ideal Cabin Environment Project (ICE—see Item 1.9).
| BRE (ex-Building Research Establishment), acting for DFT and DH, conducted a wide ranging, EC-funded research programme, Cabinair, into the health and comfort issues involved in cabin air quality. The work was extended to include measurements on older aircraft types and was carried out between July 2002 and October 2003. Titled the "Study of air quality in the aircraft cabin" it was published on the DFT website in 2004.
The CAA raised the subject of a need to review the existing airworthiness requirements on ventilation and cabin air quality in the applicable JAA working group. EASA has since assumed responsibility in this area. In 2003, the CAA, together with DGAC France, produced a paper detailing the range of issues that needed to be addressed and the proposed constitution and terms of reference of an authority/industry working group. This was taken to EASA for consideration of further action. EASA now intends to issue an A-NPA (Advance Notice of Proposed Amendment) based on these proposals to assess support for further action. The action is in the EASA rulemaking work programme for the second half of 2007.
|
| 1.24 We recommend the Government to urge JAA to reconsider its requirement for ventilation of the flight deck with only fresh air (Paragraph 5.17).
| This recommendation appears to be based on a misunderstanding over the JAA's requirement for ventilation of the flight deck. The Government notes that this requirement does not specify the exclusive use of fresh air on the flight deck.
| |
Air Quality
1.25 Passengers' perception of general cabin air quality is one of the key factors in their assessment of the flight experience as a whole. We recommend that airlines collect, record and use at least some of the basic cabin environment data being continuously monitored, not only to give authoritative substance to their refutation of common allegations, but also to provide a better basis for public confidence in these matters.(Para 5.49)
| Both aircraft manufacturers and airlines have made information on cabin air quality available, for example in publications and on websites. This information is also made readily available to the media, who exercise the right to choose which sources of information they use.
| Material on cabin air has been published on a number of websites, including;
CAA http://www.caa.co.uk/default.aspx?catid=
3&pagetype=90& pageid=1345
British Airways http://www.britishairways.com/
travel/healthcabair/public/en_gb
Thomas Cook http://www.thomascookairlines.co.uk/
Your_Wellbeing_in_the_Air.htm
|
| 1.26 We recommend airlines to carry out simple and inexpensive cabin atmosphere sampling programmes from time to time, and to make provision for spot-sample collection in the case of unusual circumstances. (Paragraph 5.50)
| The airlines and aircraft manufacturers would welcome the availability of suitable technology to allow routine sampling and spot-sampling as described. Equipment currently available requires careful setting up and rigorous calibration, and is therefore not suitable for routine use.
| DFT is preparing an in-flight cabin air sampling research project—see paragraph 11 of the joint DFT DH CAA memorandum to the Committee.
|
| 1.27 We welcome the ASHRAE work on cabin air quality standards and recommend the industry to support and encourage its timely completion and promulgation. We recommend that, in the light of the outcome, regulators consider extending cabin air quality standards beyond those for carbon dioxide, carbon monoxide and ozone for which they already provide (Paragraph 5.51).
| The Government accepts this recommendation. Depending upon the results of the ASHRAE* work, the CAA will consider whether cabin air quality standards should be extended beyond those for carbon dioxide, carbon monoxide and ozone.
*American Society of Heating, Refrigerating and Air-Conditioning Engineers
| In 2004, the ASHRAE* SPC161P committee finalised a proposed standard for cabin air quality on commercial aircraft in the USA, which went out for consultation, as a result of which, amendments were made, and it has been redistributed for further consultation. It is being discussed at the forthcoming ASHRAE Conference in Long Beach, 23-27 June 2007.
|
| | AHU attended the ASHRAE conference in Quebec in June, 2006. The CAA raised the subject of a need to review the existing airworthiness requirements on ventilation and cabin air quality in the applicable JAA working group.
|
| | There is a European pre-standard, prEN4618. ASD-STAN* prepared a standard (the CAA was represented on the drafting committee) which was voted on and accepted by all Member States. The standard was published in September 2004. At present, it is the only international standard used in Europe. Users include Airbus. It is intended to make this standard mandatory (SEN), in 2006-07.
|
| | *ASD-STAN establishes, develops and maintains standards requested by the European aerospace industry. It is well recognised as the European body for the development of global aerospace standards by the International Aerospace Quality Group (IAQG).
See also response to 1.23
|
| 1.28 We recommend the Government to urge ICAO to upgrade the smoking ban recommendation to a formal requirement on its Member States in relation to all flights (paragraph 4.31). Pending a formal ban, we recommend those airlines which still permit in-flight smoking to complete the ban on a voluntary basis.
Where in-flight smoking may still be permitted, we recommend that airlines and their agents should actively make this clear to intending passengers prior to ticket purchase. (Paragraph 4.31)
| The current status of the ICAO recommendation is appropriate in that it allows those countries who wish to ban smoking to do so, while allowing those countries which prefer to leave such choices to the airlines to do so.
Virtually all passengers flying to or from the UK now do so on a flight on which smoking is banned. We would be reluctant to press for a worldwide ban in ICAO when the practical impact on passengers travelling to and from the UK would be so limited.
This recommendation is for airlines to consider, but the Government notes that a similar proposal is currently on the table in discussions between airline representative organisations and passenger groups on a possible voluntary charter on passenger rights in Europe, following the European Commission's Communication on Air Passenger Rights of July 2000.
| The Air Navigation Order 2005 PART 5 Operation of Aircraft Item 76(2) states that: " A person shall not smoke in any compartment of an aircraft registered in the UK at a time when smoking is prohibited in that compartment by a notice to that effect exhibited by or on behalf of the commander of the aircraft".
No known UK registered airline permits smoking on board its aircraft and we understand that virtually no airline registered abroad that operates into the United Kingdom does either. DH will keep the situation with aircraft under review, and if smoking on commercial aircraft is permitted in the future, powers exist to make regulatory provision to protect passengers from second-hand smoke.
|
| 1.29 To minimise potential health problems when aircraft fly through ozone plumes, we recommend airlines to fit ozone converters to their aircraft used on routes where they may come into contact with such plumes. (Paragraph 4.47)
| All BATA member airlines operating long-haul routes have fitted or are fitting ozone converters to all long-haul aircraft.
| The current understanding is that this issue only applies on routes close to the poles where ozone plumes are sometimes reported. The vast majority of BATA members' long-haul fleets are equipped with ozone converters, including BA and Virgin Atlantic, the predominant long-haul carriers. Boeing 747 and Airbus A330 aircraft are fitted, but most Boeing 767 aircraft are not. The charter airlines operate a mix of 767 and A330 aircraft on long-haul and one of these is approaching Boeing to see if ozone converters can be retro-fitted to its existing fleet.
|
| 1.30 We recommend airlines review and modify their cabin design considerations to include [air nozzles under personal control]. (Paragraph 5.40)
| Aircraft ventilation systems are designed to provide effective ventilation air flows for all passengers. The installation of `individual' air nozzles is not an issue of relevance to health and should remain an option for the airline to determine.
| There are no airworthiness requirements for individual ventilation outlets for passengers. Individual air nozzles are not now universally fitted on newer aircraft and have to be requested from the manufacturers at extra cost.
|
| Transmission of Infection |
| |
| 1.31 We recommend the Government and airlines to do more to dissuade intending passengers from flying while they are likely to infect others. This could be further reinforced by a reminder that boarding may be denied to those who are obviously infectious (Paragraph 7.33)
| DH will be considering how to broaden the dissemination of health information for intending airline passengers, stressing the importance of individual responsibilities.
| The National Travel Health Network and Centre (NaTHNaC) is funded by the DH to promote clinical standards in travel medicine. General advice for travellers is on the NaTHNaC website at http://www.nathnac.org/yellow_book/13.htm.
|
| | This site is regularly updated, and there is a steering committee comprising DH, Health Protection Agency and other experts. NaTHNaC works closely with FCO and the travel industry, to review guidance and to provide up to date information on current issues.
|
| | The UK Government has a policy on travel advice at Phases 3-6 of a pandemic influenza which is in line with WHO advice, The websites above will be updated as appropriate as any pandemic advances.
|
| | The FCO site at http://www.fco.gov.uk/servlet/Front?pagename=
OpenMarket/Xcelerate/ShowPage&c=
Page&cid=1115137377255 already advises British Nationals overseas that they should take personal responsibility for their health during a pandemic.
|
| 1.32 To reduce cross-infection risks, we recommend airlines to ensure they have suitable policies for occasions when aircraft with passengers on board have to be held on the ground for long periods without suitable ventilation. (Para 7.22)
| Aircraft on the ground are normally provided with ventilation via either the Auxiliary Power Unit or ground power.
| |
1.33 We recommend the Government to consider requiring UK airlines and their agents to retain all aircraft passenger information which could be useful in tracing contacts for a minimum of three months after all flights, and that the Government should seek to extend this requirement internationally (Paragraph 7.40).
| The Government would be reluctant to impose obligations on UK carriers unilaterally because of the impact such action could have on their international competitiveness. The Government hopes that ICAO will be able to agree on recommendations for Member States to follow up with their respective airlines and public authorities, and that IATA will consider refining its recommended practice on the carriage of passengers with infectious diseases. In the longer term another possible means of international action may be for the WHO International Health Regulations to be amended to include tuberculosis.
| ICAO Assembly Resolution A35-12, Protection of the health of passengers and crews and prevention of the spread of communicable disease through international travel requests the Council, inter alia, to review existing Standards and Recommended Practices (SARPs) related to passenger and crew health. ICAO is keen to develop and update its SARPs, aligning them with the new IHR. ICAO Secretariat proposes that a new Recommended Practice be included, regarding the use of a "Passenger Locator Card" for use by air transport operators in the case of a suspected case or outbreak of a communicable disease. The card has been developed jointly by the International Air Transport Association (IATA) and the World Health Organization (WHO), and encourages compliance with Article 23 (1) of the International Health Regulations (2005) which states: "Subject to applicable international agreements and relevant articles of these Regulations, a State Party may require for public health purposes, on arrival or departure: (a) with regard to travellers: (i) information concerning the traveller's destination so that the traveller may be contacted; (ii) information concerning the traveller's itinerary to ascertain if there was any travel in or near an affected area or other possible contacts with infection or contamination prior to arrival."
|
| | The International Health Regulations 2005 were agreed globally and came into force on 15 June 2007. They provide a framework for a comprehensive response to the risks of infectious disease and to chemical and radiological contamination. The WHO issued the 2nd edition in January 2006 of Air travel and tuberculosis. Guidelines for Prevention and Control. It can be found on:
http:// whqlibdoc.who.int/hq/
2006/WHO_HTM_TB_2006.363_eng.pdf
|
1.34 From time to time, airlines and their representative bodies review the passenger data collected for marketing and other analytical purposes. In doing so we recommend they also consider improving such data (or at least ensuring greater standardisation) to help meet the potential needs of post-flight contact tracing. (Paragraph 7.41)
| The data collected for market research purposes is not intended or appropriate for post-flight contact tracing. In accordance with the principles of the Data Protection legislation, data intended to support post-flight contact tracing should be collected for that express purpose.
| |
Filtration | |
|
1.35 We recommend the industry as a whole to review and substantially improve overall in-service performance monitoring of filters. (Paragraph 7.24)
| Aircraft filtration units are operated and serviced in accordance with the manufacturer's design and operating specifications. This ensures that the filters perform to the specified standard throughout their period of installation.
| |
1.36 To minimise the risk of cross-infection, we are clear that it should be, and we recommend the Government and regulators to make filtration to best HEPA standards mandatory in re-circulatory systems (Paragraph 7.26)
| The Government accepts that the standard of filtration is a key contributor to minimising the potential for cross-infection in aircraft using re-circulatory ventilation. The vast majority of passengers flying on UK aircraft will experience HEPA standard filtration, but the AHWG will continue to promote the use of HEPA standard filtration on those aircraft where such standards are not achieved.
| The great majority of aircraft capable of being fitted with filters are equipped with HEPA filtration.
There are no airworthiness requirements to install filters of any kind in recirculation systems. Most aircraft do have them but some do not. The grade of filter used is a customer option, though it is almost a universal standard now, particularly on larger airliners, to have HEPA filters. However this is at the discretion of the manufacturer and customer. Any move to mandate the installation of HEPA filters would need to originate from a health aspect.
|
Noise | |
|
1.37 We recommend airlines to extend the inexpensive courtesy of offering free earplugs to all passengers. (Paragraph 6.55)
| The cost of such a measure would be considerable and, in the absence of a noise hazard, unjustifiable. Passengers who wish to use earplugs may choose to purchase a product which suits them.
| |
1.38 The British Airline Pilots Association (BALPA) made the point on behalf of pilots that, although cockpit background noise is within acceptable limits, the addition of radio communication noise can cause the noise at the ear to exceed levels at which hearing protection would be required by law if flight-decks were not exempt from the Noise at Work Regulations. As this may have both health and wider safety implications, we recommend CAA and the Health and Safety Executive (HSE) to investigate the matter further (Paragraph 6.57).
| The CAA recognises that cockpit noise could cause damage to hearing, although it is very unusual to ground a pilot permanently because hearing is sufficiently impaired to preclude safe flying. We understand that British Airways have investigated noise in the cockpit, and as a result they and other airlines have introduced noise-attenuating headsets. This is an example of the "duty of care" of an employer, and the CAA takes the view that that is where the primary responsibility for change rests. However, the AHWG will investigate this matter further and, if necessary, consider research into noise levels in the cockpit.
| The Aviation Occupational Health and Safety Working Group is looking at this.
In relation to the European Directive 2003/10/EC Physical Agents (Noise) Directive, implemented in the UK by the new Control of Noise at Work Regulations 2005 (SI 2005/1643), the exemption in relation to aircraft was removed. These Regulations are enforced by the HSE—The HSE guidance on the Regulations (L108 Controlling Noise at Work) goes on to clarify at paragraph 25 that `the Noise Regulations apply to aircraft in flight over British soil'—although in relation to on board cabin noise it is likely that the Memorandum of Understanding between the CAA and HSE would be taken into account to avoid duplication of enforcement effort.
|
Stress | |
|
1.39 Noting the inter-relationship between comfort and stress and health, together with the scope for combined adverse effect with other environmental factors, we recommend that, when investigations are conducted into the impact of any particular environmental factor on health or wellbeing, the possibility of combined effects be given appropriate attention (Paragraph 6.63)
| The scoping study, which is currently being undertaken, will assess any existing research on combined effects and, if there is a need, recommend the commissioning of further work.
| The inter-relationship between health and well-being, including stress, is part of the ICE project (see Item 1.9).
|
1.40 We recommend airlines to review their arrangements for the timing of refreshments and sleep periods on long-haul flights with jet-lag in mind, and also to advise passengers at booking and in-flight about appropriate measures to deal with the effects. (Paragraph 6.65)
| Advice and information on the effects of trans-meridian flight are provided by a number of airlines. However, the effects and solutions vary between individuals and the passengers on flights may have originated from different time zones. Arrangements for meals, entertainment etc must therefore reflect the preferences of the majority of passengers, as indicated by market research and customer feedback.
| The British Airways and NHS Direct websites give advice on jet lag.
|
In Flight medical emergencies |
| |
1.41 Bearing in mind the greater numbers and range of people travelling by air, we recommend the Government to upgrade the required minimum provision by UK carriers for medical emergencies to current "best practice" levels in relation to both crew training and medical emergency kits. The latter should include automatic external defibrillators (AEDs) on at least long-haul aircraft (paragraph. Furthermore, we recommend CAA to work through JAA to secure similar improvements across Europe (Paragraph 7.77).
| Any proposal to enhance the minimum level in respect of medical kits and equipment, including any associated increase in medical training for crew/cabin staff, would require re-negotiation with JAA Member States. UK airlines are at the forefront of ensuring high standards for dealing with medical emergencies—for instance, most UK long-haul carriers now ensure in-flight defibrillators are carried as standard. The Government recognises the importance of spreading good practice, and this will be taken forward in the AHWG.
| The Head of the AHU carried out research with three major British airlines to assess the outcomes of defibrillator use. Universally, the success rate was low; the likely reason for this being a lower prevalence of treatable heart rhythm in airline passengers (approximately 30%) compared to that seen in the population at large (approximately 70%). These data would not support mandating defibrillators at this point in time. But we do not expect to see any change in the common practice for long-haul flights to carry them.
|
1.42 We recommend all long-haul airlines to consider engaging contracted ground based expert medical services.
| Most UK operators of long-haul aircraft do subscribe to such a service.
| |
Research | |
|
1.43 Our Inquiry has already shown where the major gaps in knowledge are and we recommend the Government to commission research into the following matters as the highest priority:
(a) the epidemiology of DVT, by a case-control type study;
(b) the demography of air travellers and the types and frequency of travel undertaken;
(c) real time monitoring of air quality and other aspects of the cabin environment, with a view to establishing new and clear regulatory minima for passenger cabin ventilation;
(d) testing, with the latest non-invasive technology, blood oxygen levels across the whole spectrum of air travellers, to validate conclusions derived from data on young healthy adults;
(e)exploration of the ways different aspects of the aircraft cabin environment may interact, particularly on those in less than average health; and
(f) extracting maximum value from available and improved medical records of aircrew concerning any long-term effects from exposure to the aircraft cabin environment (Paragraph 9.3)
| The Government shares the view that there are gaps in current knowledge of health issues related to air travel. Stage II of the Government's current study will assess the existing knowledge base across a range of issues and recommend where further research would be best targeted.
As regards the specific areas identified by the Committee:
(a) The Government envisages initiating a case-control type study once Stage II of its current study is complete;
(b) A case-control type study of DVT should go some way to providing detailed demographic information on air travel which may also be of use in assessing levels of risk in a number of health areas. The AHWG will consider the findings of research into DVT insofar as they provide information on demographic differences in levels of risk and consider whether this information is relevant to other health issues. Further research maybe necessary.
(c) Stage II of the study will now assess the existing research on air quality, and recommend what further research is needed.
(d) The research, which is envisaged on air quality, will give consideration to the need to test the effect of varying blood oxygen levels across the whole spectrum of air travellers. Also, the work on deep vein thrombosis will give consideration to aspects that are specific to the aircraft cabin environment, such as reduced oxygen levels, if the scoping study which we have commissioned reveals that such work has not been carried out.
(e) the Government recognises that different aspects of the cabin environment may have cumulative effects on certain passengers and will consider this recommendation in the light of results emerging from Stage II of its current study; and
(f) the CAA has initiated a research project to cross-reference aircrew medical records to the types of flying undertaken and the subject's subsequent medical history.
| We have already mentioned (see item 1.8) three areas where research effort has been focused; DVT, potential cabin air contamination, ICE.
In relation to point (f) There has been a range of international studies of the health of cabin and flight crew, including a European study of mortality/cancer incidence among flight and cabin crew and NIOSH (National Institute for Occupational Safety and Health) studies of flight attendant fertility/ pregnancy outcomes. The only consistently reported adverse health outcome has been a higher incidence of melanoma amongst flight crew (which, it is thought, may be related to lifestyle factors).
Dr Sally Evans, the CAA's Chief Medical Officer is currently undertaking a study, in conjunction with the London School of Hygiene and Tropical Medicine, into the mortality and cancer incidence of commercial aircrew and Air Traffic Control Officers (ATCOs), comparing the risks with that of the general population, matched for age, sex and socio-economic group. The study began in 1997 and preliminary results are being prepared for publication. The study will become more valid with time, as more of the cohort develop cancers or die.
|
Information for passengers |
| |
1.44 We recommend the Government to require airlines and their agents to provide more information for passengers at the time of booking on:
(a) the size of seat that is on offer, using unambiguous standardised definitions;
(b) options for pre-booking seats, particularly those with extra leg-room;
(c) whether smoking will be permitted on the flight in question;
(d) the need for sub-aqua divers to ensure that the effects of any recent diving will not create an additional hazard when they fly;
(e) the need for intending passengers to satisfy themselves that they are generally fit to fly—not only for their own health (particularly in relation to DVT) but also for that of others; and
(f) in the case of long-haul passengers, measures to deal with the effects of jet-lag (Paragraph 9.5)
| The AHWG will look at the provision of information and consider whether specific research is required in order to establish the most effective way to ensure health information reaches passengers. The Working Group will also monitor the information given by airlines and other parties to ensure that this meets the needs of passengers. As regards the recommendations for the provision of specific information:
(a) Refinement of definitions of seat pitch must await the conclusion of the CAA-funded research described above;
(b) whilst most airlines allow passengers to pre-book seats, including those with extra leg-room, the Government accepts that information about this facility could be more widely disseminated and, through the AHWG, will encourage airlines to offer this information more effectively;
(c) this proposal is currently under active consideration in discussions in Europe;
(d) whilst not underplaying the risks to sub-aqua divers, it would appear disproportionate to require all airlines to provide this information to all passengers. The Government will consider this issue in the Aviation Health Working Group with a view to pursuing the matter with the relevant representative organisations;
(e) and (f) the information contained in the booklet "Health Advice for Travellers" is available via the DH internet web site. DH Communications Division are currently exploring ways in which wider health- related travel advice might be provided through the DH web site, and also how links might be developed with NHS Direct and NHS Direct on-line.
| As mentioned, the internet has a wealth of travel health information from airlines and Government agencies.
On (d) there have been no inquiries about this issue in last few years. We assume this is covered in specialist diving websites.
|
1.45 The importance of fitness to fly needs to be given suitable prominence. We recommend that, at every ticket sale point and in every doctor's surgery, there should be a small display card asking intending passengers, "Are you fit to fly?" To help them find the answer, this could offer a short and user-friendly note of guidance (Paragraph 9.6).
| Although doctors are unlikely to see it as a high priority to display general information on air travel and health, other than in travel clinics, it may be that such information could be provided in a leaflet, or as part of a questionnaire issued to patients while their travel needs are being assessed. DH will consider this further and report to the AHWG.
| Government is not aware of a general problem of people flying while unfit. A bigger problem is people who need medical treatment abroad and who are not insured. This has been highlighted by FCO and Treasury's recent review of travel insurance. Concerns over possible medical costs are likely to encourage people with medical conditions to seek advice before travelling.
|
1.46 Passengers need to be reminded on boarding and in-flight about the simple measures that minimise any risk of flight-related DVT, and of the simple measures to alleviate head pain from pressure changes on take-off and landing. We recommend the Government to require airlines to provide, immediately before take-off, a health briefing comparable to the already required safety briefing, backed up by a standardised card in seat-back pockets (Paragraph 9.8).
| The Government is aware that UK airlines are actively considering, and in several cases have already introduced, means of passing on relevant heath information to on-board passengers, and is not of the view that regulation is necessary at this stage. But through the AHWG it will monitor the effectiveness of the health briefing offered to passengers and take whatever further steps may be necessary.
| Airlines are making positive efforts to provide accurate and user friendly information. For example, Monarch provide information on DVT in their in-flight magazine as well as on the in-flight entertainment videos.
|
1.47 We recommend 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 review should include the case for an independent `ombudsman'. (Paragraph 8.60)
| UK airlines carry millions of satisfied customers. In addition, the vast majority of complaints are handled efficiently and to the customers' satisfaction. All BATA member airlines have signed up to the European voluntary commitment on Air Passenger Rights. Amongst other things in this fourteen point document, airlines have committed themselves to timely resolution of complaints. Some complainants start with an expectation of financial /ticket/upgrade rewards that are inappropriate and cannot/ should not be met. Where complainants indicate in their letter that they are considering legal action, they should reasonably expect the airline's legal / insurance advisers to be involved.
| This recommendation arose out of general comments about how airlines treated passengers. In terms of specific complaints seating and space limitations came in for adverse criticism (para 8.54)
The Air Transport Users Council (AUC) has noted that while many passengers do complain about stuffy cabin air, uncomfortable seating, etc it is often an add-on to another complaint and so does not get counted. AUC has had 206 specific complaints about uncomfortable seating/seat pitch since April 2002 when it started recording numbers. This compares with around 10,000 total complaints in the single year 2005-06, mainly about delays, cancellations and mishandled baggage.
|
