Richard Westgate

PFD Report All Responded Ref: 2015-0050
Date of Report 16 February 2015
Coroner Sheriff Stanhope Payne
Coroner Area Dorset
Response Deadline est. 13 April 2015
All 2 responses received · Deadline: 13 Apr 2015
Sent To
Response Status
Responses 2 of 2
56-Day Deadline 13 Apr 2015
All responses received
About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Coroners Concerns
_ That organo-phosphate compounds are present in aircraft cabin air.

(2) That the occupants of aircraft cabins are exposed to organo-phosphate compounds with consequential damage to their health.

(3) That impairment to the health of those controlling aircraft may lead to the death of occupants_ (4) There is no real time monitoring to detect such compounds in cabin air; (5) That no account is taken of genetic variation in the human species, such as would render individuals tolerant or intolerant of the exposure_
Responses
Civil Aviation Authority
10 Apr 2015
Response received
View full response
Dear Sir Richard Mark WESTGATE Deceased Further to your Report to Prevent Future Deaths made under Schedule 5, para 7 Coroners and Justice Act 2009 and Regulation 28 Coroners (Investigations) Regulations 2013 dated 16 February 2015 ("the PFD Report") , am writing to provide you with the CAA's response as required by 13 April 2015. The CAA takes its regulatory responsibilities regarding passenger and crew health very seriously. The subject of cabin air quality has been considered by several expert studies over the years as referred to in the annex to the CAA's letter to you dated 23 March 2015, a copy of which we attach as an annex t0 this response_ The overall conclusion of those studies is that there is no positive evidence of a link between exposure to contaminants in cabin air and possible acute and long- term health effects, although such a link cannot be excluded As our letter also made clear, further investigations are being conducted by the European Aviation Safety Agency (EASA): EASA is an agency of the European Union (EU) with regulatory and executive tasks in the field of civilian aviation safety across the EU. EASA has recently launched a Preliminary Cabin Air Quality Measurement Campaign and the contract was awarded on 18 March 2015 following a tender process published on 31 October 2014. This preliminary measurement campaign wili develop the methodology, including validation of the equipment to be used, in performing cabin and cockpit air contamination measurements, and be followed by a first flight measurement campaign which will provide initial indications of the cabin or cockpit air quality level. It will pave the way for EASA to commence large-scale project, including an in-flight measurement campaign on board commercially operated large transport aeroplanes The EASA preliminary study is due to be completed within 20 months of the award of the tender. The CAA will cO-operate with EASA's work on cabin air quality and will review its position in due course with the benefit of the results of EASA's study. Civil Aviation Authority CAA House K5 45-59 Kingsway London WCZB 6TE

Direct Line 020 7453 6160 Fax 020 7453 6175 kate staples@caa co.uk Your will fully

In our opinion the above studies represent proportionate, evidence-based response to the concerns that have been raised about the health implications of cabin air quality for passenger and crew. were not taken in response to the PFD Report but have been ongoing for several years: would add, by way of postscript; that the evidence which has been provided to you by the legal representatives of the deceased_ and upon which the PFD Report was based, is selective and contentious and does not reflect the outcomes of these expert studies. remain of the view outlined in our letter of 23 March 2015 that it was inappropriate for the PFD Report to have been issued on the basis only of this material and without first inviting submissions from the CAA Had we been given an opportunity to apprise you of the work that is done we are confident that you would not have considered it necessary to issue the PFD Report at all: We shall be writing to the Chief Coroner in these terms inviting him to clarify his Guidance on PFD Reports. In our view, if Coroner is concerned from information he has obtained that circumstances creating a risk of other deaths will occur, or will continue to exist in future, the Coroner should first establish (a) whether those concerns are reflected by information that he has not seen and (b) what action is already taken to prevent the occurrence or continuation of such circumstances before issuing a PFD Report: The obvious way of doing that is to invite representations from the relevant public body
British Airways Plc
13 Apr 2015
Response received
View full response
Dear Sir Richard Mark Westgate (Deceased) Regulation 28 Response This letter is British Airways Plc'$ Response to the Report to Prevent Future Deaths issued by the Senior Coroner for Dorset dated 16 February 2015_ This Response is made pursuant to Regulation 29(3)(b) of The Coroners (Investigations) Regulations 2013_ BA notes the matters of concern set out by the Coroner in the Report to Prevent Future Deaths. BA has given, and continues to give, the most serious consideration to the issue of cabin air quality. The Matters of Concern in the Report to Prevent Future Deaths have been fully dealt with by official Government and regulatory bodies: have studied the issue of cabin air contamination; and have provided guidance for airlines (including BA) to follow: The evidence does not support the conclusion that there is a risk that future deaths will occur unless action is taken: The most recent example of such advice may be found in the Committee on Toxicity's ("COT") Position Paper on Cabin Air in 2013. Those regulatory investigations are continuing with the recently announced decision of EASA to undertake further research in the area: BA follows the guidance ad legislation to which it is subject. BA abreast of research in this area, and has in place a system of monitoring such events The available evidence does not suggest that organophosphate chemicals are present in cabin air in sufficient quantities to pose a risk to health evidence with which you have been presented ad which led to the issue of the Report unfortunately was selective and provided by only one Interested Party: We regard the future course of the Investigation as an opportunity to provide you with balanced and fully evidence-based view on the Matters of Concern: It is understood that the CAA concur with this view:
Action Should Be Taken
In my opinion urgent action should be taken to prevent future deaths and | believe your organisation has the power to take such action
Report Sections
Investigation and Inquest
On 27th December 2012 commenced an investigation into the death of
Circumstances of the Death
On 12th December 2012 Richard Mark Westgate was found deceased in his room at the Bastion Hotel in Bussum, Netherlands. His body was repatriated to Dorset. He was a British Airways pilot who had been on medical leave since September 2011 suffering cognitive dysfunction, ataxia & other deficits_ Post mortem examinations gave causes of death of either Pentobarbital toxicity or lymphocytic myocarditis, individually or in combination_ Testing ofsamples taken both prior to and after death disclosed symptoms consistent with exposure to organo-phosphate compounds in aircraft cabin air. Such exposure can cause lymphocytic myocarditis_ Stafford Road, Bournemouth_ Dorset; BHI IPA Tel 01202 454910 Fax 01202 780423 yet

Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.