Richard Westgate

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Direct ne
S.S. Payne Our Ref:
Your Ref:

H. M. Senior Coroner

The Coroner's Court

Stafford Road

Bournemouth

BH1 1PA 13 April 2015

Dear Sir

Richard Mark Westgate (Deceased)
Regulation 28 Res

This letter is British Airways Plc’s 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. They 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 and legislation to which it is subject. BA keeps 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. The evidence with which you have been presented and 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 a balanced and fully evidence-based
view on the Matters of Concern.

It is understood that the CAA concur with this view.

Yours faithfully

gL

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Office of the General Counsel

Civil Aviation
Authority

S.S. Payne

H M Senior Coroner
The Coroner's Court
Stafford Road
Bournemouth
Dorset BH1 1PA

10 April 2015
Our Ref:

Your Ref as

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 to 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 will develop the methodology, including validation of the equipment to be used, in
performing cabin and cockpit air contamination measurements, and will 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 a 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 fully 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 KS 45-59 Kingsway London WC2B6TE www.caa.co.uk
Direct Line 020 7453 6160 Fax 020 7453 6175 kate.staples@caa.co.uk

In our opinion the above studies represent a proportionate, evidence-based response to the
concerns that have been raised about the health implications of cabin air quality for passenger and
crew. They were not taken in response to the PFD Report but have been ongoing for several
years.

We 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. We 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 being 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 a 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 being 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.

Yours faithfully

iy

General Counsel and Secretary to the CAA

enc.