Does the crew open and examine the first aid box before the flight takes off to know if there is a deficiency?
Aviation Safety: Presentation (Resumed).
Mr. Humphreys
No. It is an unfortunate occurrence when a person dies of natural causes and happens to be on an aeroplane. Deputy Connaughton's example of a road traffic accident is not comparable. A person may drop dead on the street.
I refer to the investigation that would take place.
Mr. Humphreys
Under the international convention, a person dying by natural causes where the wound is self-inflicted or where the person is a stowaway is not considered to be an accident. It is not for the aviation or accident investigation bodies to investigate that. It is up to judicial authorities in the jurisdiction to investigate.
We accept that. It is not the role of the Irish Aviation Authority to investigate accidents. However, it is the role of the authority to verify that equipment on aeroplanes functions at all times. Mr. Humphreys told the committee first that the Irish Aviation Authority carries out its checks but does not examine the medical kits, even on a random basis. He then told the committee that the crew checks the kits before the plane takes off, but this is exactly the same check because the crew does not open the box. It is terrible that random checks of equipment are not carried out with verification that the contents of the kits conform to specifications. We are not suggesting opening equipment that costs €3,000 to replace. The kits may cost up to €30. There should be a random test of a certain amount of these kits. It is a terrible indictment of the system that these are not fully checked. A fire extinguisher, for example, must be fully tested before it can be certified. There are numerous ways to re-seal equipment once it has been tested.
Mr. Humphreys
I think the medical requirement is that it must be disposed of.
Will Mr. Humphreys explain why the big kit cannot be on short-haul flights?
Dr. Roodenburg
It is considered by the experts to be useless on such flights. The kits should only to be used in circumstances where one cannot bring the patient to a treatment centre. I do not know if the Deputy has ever seen a medical incident on an aircraft but doctors and assistants often feel helpless. There is very little space and there is so much noise that doctors cannot even hear through their stethoscopes. There is not much that doctors can do so they try to move the patient as quickly as possible to a location that enables them to be of real assistance. If one is on a short-haul flight, one immediately goes to an airport. However, if one is on a long-haul flight and knows one cannot reach an airport quickly, then the kit might be of use. The ultimate aim should be not to use the kit but to bring the patient to safe surroundings for treatment as soon as possible.
That is difficult to understand because even on a short-haul flight, if an aircraft must be turned around, it would generally be at least half an hour before the aeroplane could land. A great deal of damage could be done in that time.
Dr. Roodenburg
Yes, but it depends on the accident. If one is dealing with a bleeding cut, one can do something straight away. It is likewise if one is dealing with a respiratory incident where a patient is not choking. However, if one must do something to clear a patient's airways, it is better to wait and do so in a controlled environment.
Can the representatives answer the questions that were asked earlier? I am interested in their responses but must leave soon to attend another meeting
We have rambled away from the original query. There appears to be some confusion whether correspondence was received from the two nurses.
Mr. Humphreys has accepted that he received correspondence and has sent a standard reply dealing with the overall situation but not with the specific incident in question. Is that correct, Mr. Humphreys?
Mr. Humphreys
My understanding is that the correspondence received from Ms Douglas was in the form of a questionnaire. It contained questions regarding the training required, the equipment carried on aircraft and so forth and the standard reply to which the Chairman referred was sent to her in response.
There are many contradictions surrounding this specific incident. I am not questioning the broader issues. I agree——
I ask Deputy Wilkinson to refrain from summing up until Mr. Humphreys replies to the questions posed by various members.
Mr. Humphreys
Deputy Timmins referred to defibrillators. When I was the chief inspector of accidents, I recommended to the International Civil Aviation Organisation, ICAO, that defibrillators be carried on board aircraft and crews be trained in their use. When the ICAO decrees that something is a standard, every aeroplane must comply with it. In the western world we do not have too much difficulty getting people to comply with the standards. However, there is a difficulty for the rest of the world in keeping up when the wealthier countries set very high standards, with newer aircraft and systems. When I made that recommendation to the ICAO it responded——
When was that?
Mr. Humphreys
In 2004.
Is that the recommendation to which I referred earlier?
Mr. Humphreys
Yes, I think so. The ICAO is the organisation which decides what the standard should be. The organisation is comprised of 187 states and is the only body that has the power to apply a worldwide standard, with total co-operation——
The standards are so low as to be non-existent.
Mr. Humphreys
I do not accept that. There has not been one fatal——
I apologise for interrupting, but will Mr. Humphreys deal with Deputy Brady's question?
We are rambling all over the place.
Mr. Humphreys
The Deputy referred to the matter of defibrillators.
No, the question I asked concerned first aid, the qualifications of crews and so forth.
Mr. Humphreys
During their initial training, all cabin crews are given first aid training. They are then checked annually on that training.
I asked if crews were regularly sent on training courses, if their training was updated on a quarterly basis, whether first aid drills take place and so forth.
Mr. Humphreys
They are trained at their initial——
Are they checked? Are they assessed?
Mr. Humphreys
They are trained at their initial training and assessed every year.
They are assessed every year.
Mr. Humphreys
Yes. The Deputy also asked about defibrillators.
No, I did not. I asked if crew members would know if a person on board suffered from epilepsy or diabetes or whether passengers should convey such information to them. I suffer with diabetes and must take insulin. Would cabin crew members know whether a medical doctor is on board prior to an aeroplane taking off?
Dr. Roodenburg
Passengers are expected to declare known medical conditions when making a reservation prior to travelling. Then the airline can decide whether the passenger is deemed fit to fly and whether he or she needs medication. The onus is on the passenger to declare any medical condition.
If a passenger declares a medical condition prior to flying, would the crew members be aware of that and know what to do in the event of an emergency? This is an issue of concern for elderly people in particular.
Dr. Roodenburg
Elderly people who travel are advised——
I am asking these questions because somebody who works in the airline business, whose name I cannot mention for obvious reasons, has told me that this does not happen. I have also been told that the training is not updated. Medicine and technology is changing all the time. I have been told that crews are assessed once a year but——
Dr. Roodenburg
They are not trained according to the JAR OPS. They are not trained in how to treat epilepsy or diabetes. They are only trained in basic first aid. If one has a medical condition, it is advisable to discuss it with one's general practitioner. He or she can advise one on whether to disclose it to the airline before travelling. Airlines expect passengers to be healthy travellers unless they have declared otherwise. Airlines expect to be informed of medical conditions that might suddenly lead to incidents on board. They should be informed if a passenger has a respiratory condition and needs oxygen or special care while travelling.
Who ensures that the annual assessment to which Mr. Humphreys referred takes place?
Mr. Humphreys
The Irish Aviation Authority checks that the training and the checking has been carried out by the operator. It is up to the operator to ensure it is done. The Irish Aviation Authority cannot——
How does one know it has been done?
Mr. Humphreys
The operators maintain records and those records are inspected.
On what basis is that done?
Mr. Humphreys
There is a requirement under European regulations——
We do not dispute that but what is the actual mechanism for checking——
Mr. Humphreys
It is an audit——
——that Deputy Timmins, for example, has done his medical checkover and training for the year?
Mr. Humphreys
The airlines are required to maintain safety management and quality systems. The quality system is supposed to audit the safety management system to ensure the checks are done. Then the authority carries out a random check.
The authority would do a random check on air hostesses, for example.
Mr. Humphreys
Yes. The authority would go to an airline and examine the training records of a specific number of staff.
Does Mr. Humphreys consider once a year to be adequate?
Mr. Humphreys
They have to undergo training in other areas, such as evacuation and decompression.
We are not interested in anything today but first aid.
Mr. Humphreys
I am not qualified to comment on first aid but I had hoped to outline for Deputy Timmins the opinion of the International Civil Aviation Organisation.
Mr. Humphreys addressed that issue before Deputy Timmins arrived but I have no problem with him repeating his explanation.
Does Dr. Roodenburg consider one day of training per year for frontline airline staff adequate to keep them updated on the medical emergencies which could arise?
Dr. Roodenburg
Staff are not supposed to be able to react to any occurrence but are trained for the general situations which can be expected to arise, for example, an anxiety attack or a fainting passenger. Lengthy discussions were held between the experts in the airline industry, medical advisers and authorities with regard to the training needs of aircraft crew, the conclusion of which is outlined in JAR OPS. The training provided is considered by the experts to be sufficient and no evidence exists to suggest otherwise.
As someone who was involved in administering first aid, I know that first aiders should understand how to treat people suffering epileptic fits and how to prioritise patients for treatment. I am surprised to hear Dr. Roodenburg say it is not the job of a first aider to deal with someone experiencing an epileptic fit.
Dr. Roodenburg
Perhaps I did not explain myself clearly enough. It is not the case that they should avoid dealing with such emergencies but that they are trained to handle the normal eventualities which arise on aircraft. They are not preparing to qualify for an orange cross, which in the Netherlands indicates they are registered first aid helpers. JAR OPS sets out what cabin attendants should know about first aid while they are working on an aircraft. The two forms of first aid are not entirely comparable.
Does the Department of Transport not have the authority to require airlines to carry defibrillators on aircraft which pass through Irish airspace or airports?
Mr. Humphreys
No. We could have special requirements but the normal position is that we apply the international and European standards.
It is therefore a case of applying the lowest common denominator.
Mr. Humphreys
A unilateral requirement would mean that our citizens could travel on an aircraft which is not carrying a defibrillator. The trend in international aviation is to try to harmonise regulations.
The medical equipment required on a 40-year-old aeroplane flying through the bush is the same as that required on modern aircraft. Different standards obtain for cars according to where they are sold and what the market will meet. However, Mr Humphreys is saying that, as far as equipment on aircraft is concerned, the lowest common denominator and the bare minimum applies across the globe.
Mr. Humphreys
No, that is not what I am saying at all. First aid kits are stocked according to the joint aviation requirement. That has nothing to do with the standards referred to by the Chairman. I do not know whether car manufacturers recommend what type of first aid kit should be carried in a car.
Motor manufacturers recommend safety equipment such as airbags.
Mr. Humphreys
That is covered in aviation regulations on seatbelts, restraining devices and other equipment.
Mr. Humphreys is arguing that, because 177 countries are involved in drafting regulations, the same standard applies worldwide. The standard being applied is very low.
Mr. Humphreys
The Chairman misunderstood my argument. The standard is so high that aviation is the safest method of travel. For the past 40 years, there have been no deaths in Ireland as a result of any shortcoming or deficiency in our airworthiness standards, thank God.
We are not talking about airworthiness standards because we all accept that no pilot will operate an unsafe aircraft. We are referring to the medical equipment carried on aeroplanes. Mr. Humphreys tells us that different standards apply on long-haul and short-haul routes. Why is the long-haul standard not applied universally and made mandatory for all new aircraft? Is there a genuine reason this extra equipment is not carried on short-haul routes?
Mr. Humphreys
The International Civil Aviation Organisation, in setting out the reasons for carrying an automated external defibrillator, AED, on board aircraft, states:
The rationale for carrying an AED on-board passenger aircraft has been the topic of much discussion at international aeromedical meetings during the past decade. During this period, AEDs have become smaller, lighter, cheaper and, more importantly, easier and safer to use. Today several major international airlines carry AEDs on all long-haul flights [which is the case in Ireland] and a database of inflight (or in-aircraft) use of AEDs is slowly building up. However, the clinical usefulness of on-board AEDs in commercial passenger aircraft remains debatable.
As a therapeutic tool, defibrillators are used to treat Ventricular Fibrillation (VF), the most common form of treatable cardiac arrest. VF is a common occurrence, and the survival rate is good if the shock is applied very soon after the arrest, preferably within four minutes. After the initial four minutes, cardio-pulmonary resuscitation (CPR) becomes the priority in order to prevent brain damage. However, survival decreases rapidly with time, the usual figure quoted is 10% decrease per minute delay. After seven to nine minutes, the survival rate is low and the amount of brain damage caused by lack of blood to the brain is likely to make survival less desirable.
Air passengers with VF rarely survive. CPR without shock is not particularly effective and diversion to the nearest airport and transport to a hospital will normally take an hour or more, often much longer. Defibrillation without delay is by far the best treatment. Since around 1990, an increasing number of airlines have added defibrillators to their on-board medical kit. At the same time, there has been another interesting trend towards medical telemetry which allows, for instance, an ECG from a sick passenger to be read and evaluated by a specialist on the ground and medical advice sent back to the aircraft for application in flight.
The composition of air passengers is changing towards older people, and people with more frailties and medical conditions, simply because the population in the western world is getting older and flying has become cheaper, so that even retired people can afford to fly. In addition, aircraft are becoming larger and flights longer. Because of these developments, it will become increasingly difficult to find an airport nearby to which a medical diversion can be made when needed. Consequently, many airlines have now invested in medical telemetry (teleconsultation), enhanced their medical kits, and installed AEDs for inflight use. In May 2004, the United States implemented a law requiring an AED on board all passenger carrying aircraft over a certain size.
On the basis of medical data available from British Airways, one in 11,000 passengers will have an inflight medical emergency. One in three million will die on board. One in 440,000 will be the cause of a medical diversion. Virgin Atlantic have eight times as many medical emergencies per million passengers and twice as many diversions, perhaps due to differences in passenger populations, differences in company policies, routings or reporting. With respect to the use of the on-board medical kit, statistics from British Airways and Tacoma Airport in the United States indicate that one in 34,000 passengers requires it. On average, the medical kit is used once in 227 flights, not an everyday occurrence in the life of a cabin attendant. When statistics (mostly from 1997-1999) from various United States and United Kingdom and other sources are reviewed, it appears reasonable to expect three heart attacks per 10 billion passenger-kilometres or about 635 inflight heart attacks per year worldwide. Of these about 7% are likely to be VF. That is 45 cases per year in the world where use of an AED is indicated.
A study conducted by a major airline in the United States between 1997 and 1999, covering two full years, showed that where AED shock was given to 13 passengers in cardiac arrest, the survival rate from shock to discharge from hospital was about 40%. Similar studies have been done by an Australian airline and by other United States airlines with results ranging from 26% to 62% survivors. In preparation for legislation, the Federal Aviation Administration, FAA, in the United States began collecting data in 1998, specifically asking for reports of events of cardiac origin where death would be a likely outcome. 15 airlines participated corresponding to 85% of all domestic flights in the United States. In one year, there were 177 in-flight events. Of these, 115 were cardiac [that seems to be an incorrect figure, 119 were cardiac]. Out of these, there were 17 events where an AED was used — four patients survived.
Based on these statistics, primarily from the United States, extrapolated to the entire world and applied to the 18 billion passengers who are expected to fly during the next ten years, it can be calculated that 224 human lives can be saved by installing AEDs with enhanced medical kits in all commercial passenger-carrying aircraft in the world. The cost would be around $300 million for a ten-year period, or about $1.3 million per life saved. It goes without saying that the saved lives will be of people with an average age well over 60 years and with serious pre-existing cardiovascular disease. Not all will get through this experience without some degree of brain damage and reduced life quality and few will still be alive five years after the shock, perhaps 15%.
It is difficult to determine whether the Irish incident [that I investigated] would have had a better outcome if the aircraft in question had been equipped with an AED. [In this case the pilot had a heart attack and I was more anxious that he survive because the survival of the passengers depended on his condition]. Having a defibrillator on board might have improved the outcome for the captain if he could have been shocked early. As outlined above, defibrillation needs to be undertaken as a priority within four minutes after the cardiac arrest. After ten minutes, defibrillation becomes largely ineffective. This suggests using the AED whilst the pilot is in his seat ... Getting a dead pilot, in many cases weighing over 200 pounds, out of his seat poses serious flight safety questions. Three people struggling with a heavy dead pilot in the confined area of the flight deck whilst the other pilot tries to negotiate a return to the airport, descent and landing, single handed, is not a nice scenario. It would be less problematic in cruise but still not easy. I think that airlines need to consider the scenario and review their incapacitation procedures, whether or not an AED is carried on board. The emphasis needs to be on flight safety; simply writing a procedure ... seems inappropriate as there is inadequate advice for the remaining pilot as to what his priorities should be.
Carrying, or not carrying, AEDs on board aircraft needs to be driven by whether or not the passengers would benefit. The advantage to the flight crew is small and flight safety is protected by incapacitation procedures, which have been demonstrated to be adequate because there has not been a fatal accident in two-pilot public transport operations worldwide with cardiac incapacitation as a cause for over [24] years. If an AED is carried for passenger benefit, airlines should also consider their incapacitation procedures in the light of this.
Should airlines be mandated to carry AEDs? [ICAO has] always maintained that they should not. However, that position was influenced by the lack of AEDs in other public places, airports, shopping malls, [golf clubs], train stations, etc. [to which a Deputy referred] a situation that is now changing, at least in the "developed world". Also, the equipment is now less expensive, an AED costs less than $3,000 and it has become lighter. The case in favour of carrying them is therefore now stronger than it used to be. However, I do not think their carriage should be mandated as the FAA has done. A recommendation is as far as ICAO should go, perhaps just a note or an amendment of Attachment B [that is the annex relating to this] ... As is the case with the medical kits, AEDs should be limited to larger aircraft with more than a certain number of passenger seats. Operational limitations, such as carrying AEDs on long-haul routes only, are not relevant, as the time factor in getting to an airport can be disregarded in a situation where minutes are vital. [That is why the kits are not the same].
As the response of the ICAO Medical Section indicates, the subject of the carriage of AEDs on board passenger aircraft, has been, and is under active consideration in ICAO.
That is all they are prepared to say.
What was that prepared for?
Mr. Humphreys
It was prepared in response to a recommendation I had made to the International Civil Aviation Organisation while I was in the accident investigation unit in 2004.
Therefore, it was two years ago.
Mr. Humphreys
Yes; whether it should be mandated is still being considered. We can see the arguments the ICAO is making.
The letter argues that the price of a life is $1.3 million. It is terrible because it also attacks older people and states they can be dispensed with. I do not attribute these opinions to Mr. Humphreys.
Mr. Humphreys
I could not agree.
Does Mr. Humphreys think there should be defibrillators on short-haul flights from Ireland?
Mr. Humphreys
No, but I am not a doctor.
It is the view of the American authorities.
Since we started we have flown all over the world and driven a little. Could I bring this discussion back to the original query? The two nurses involved have not been treated well by the airline representatives. Their story has been dismissed. Where do we go from here? My original request was that the two nurses come to meet representatives of the Irish Aviation Authority or the airline. I reiterate that request. I am not satisfied that what happened on the flight has been addressed. After some time Mr. Humphreys admitted he had received some correspondence from the two nurses. I do not know what he has. He may see everything I have. I am not satisfied with what I have heard. I am most surprised that when Mr. Humphreys outlines how rare a fatality is, when one did occur, the two medical people and many witnesses involved were brushed aside because the category did not fit into some grouping the airline has. I am not satisfied with this.
I ask the Chairman to invite the two nurses concerned to come to tell their story, recount how they were treated and address the issue of the medical box being removed before it was investigated. I want these issues addressed, whether by the Irish Aviation Authority, the Department of Transport or the airline. I am hopelessly unimpressed with how their case was addressed. We have established that they contacted the Irish Aviation Authority and that their story was dismissed almost as a fairytale. I cannot accept this. I request that they come with the transport representatives and those of the airline to sort out this matter, as we will not resolve it through correspondence.
We will consider the Deputy's request at the next meeting. We have a legal problem with anybody coming here. We must be conscious that while members have absolute privilege, if a witness makes an allegation against somebody, he or she will not have the same privilege. I will ask the legal adviser to the committee to give us a ruling on what should be done. While I am inclined to agree that it is fair that the people who have made the allegations should be given the opportunity to discuss them with the committee, we must be conscious of the potential legal problems. We would appreciate if Mr. Humphreys could prepare a detailed report for us on the queries raised today. The committee will make a recommendation that the minimum medical equipment to be carried on aircraft be that currently carried on all long-haul flights. We will then explore how to implement that recommendation. It is terrible to think a person on a long-haul flight has a better chance than one on a short-haul flight.
I see Dr. Roodenburg shaking her head and I am not a medic but the sooner a person who has had a heart attack receives even the minimal treatment, the better his or her chances of survival. We need to sort that out as we cannot have a two-tier system. Major cost is not involved because the difference between the cost of the equipment on short and long-haul flights is minimal in the context of the number of passengers carried by an aircraft. We can sell free seats, so surely we can afford a little extra to provide medical equipment.
Can Mr. Humphreys say when he might be able to report to us on his meeting with the nurses, Ms Scott and Ms Douglas? We will establish if the joint committee is legally allowed to invite them before us to make a submission. As far as members of the committee are concerned, this issue will not go away and we must arrive at a definite position on the equipment to be carried on aircraft.
Mr. Humphreys
I will meet the two nurses if they wish to visit us. I can ask the Belgian authorities what investigation, if any, they have carried out. I suspect the aeronautical authorities in Belgium will not have done anything. We might contact the police or the judicial authorities in Belgium to establish their position. The lady in question was an Italian citizen so there may be a judicial requirement of the Italian authorities. I do not know whether it is appropriate for me to do that.
The conventional position is that death from natural causes is not an aeroplane accident.
We all accept it is not an aeroplane accident.
Mr. Humphreys
In that case, it is not connected to aviation safety.
That last point is a grey area.
Mr. Humphreys
It is matter of health.
Maybe one could say it is a matter of aviation health. When Mr. Humphreys meets Ms Scott and Ms Douglas, I suggest Deputy Wilkinson accompany them because that might be to everyone's benefit.
Mr. Humphreys
I have no problem meeting anybody with regard to this matter. However, it is vital that the point I made about aviation safety is stressed. I do not wish to tempt fate but we have not had an accident. Great efforts are made by manufacturers, operators and all the people concerned to avoid accidents.
We all accept that nobody deliberately allows accidents to happen.
Mr. Humphreys
Accidents happen. I stress that aviation is safe, but not risk-free.
We accept that point. When can Mr. Humphreys report back to the committee?
Mr. Humphreys
Can Deputy Wilkinson contact me with a proposed date to meet with the ladies in question? In the meantime, I will get what information I can from the operator on this particular incident. As I say, it is not our normal procedure to investigate death from natural causes.
Medical death.
Mr. Humphreys
Yes.
We are not concerned with what has happened, but with what can be done to prevent it happening in the future. Any assistance that can be given might prevent a similar situation tomorrow, even if we can do nothing about yesterday.
Mr. Humphreys
I accept that is the committee's purpose.
It is everybody's purpose. It is not a witch hunt. Everybody did their best on the day but we must ask if there was anything that might have helped.
I thank Mr. Towey, Mr. Humphreys, Dr. Roodenburg and Ms Gahan, who took the minutes, for coming before the joint committee. Following this incident, we will try find what can be done to improve the situation in the long term.
The joint committee adjourned at 4.25 p.m. until 2.30 p.m. on Wednesday, 1 November 2006.