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6.11 The Committee notes that CASA, British Aerospace and Australian airlines operating the BAe 146 did not implement the recommendations of the BASI/ATSB report. It is clear to the Committee that the decision not to implement the recommendations was not justified.
6.12 It appears that Mr Mick Toller, the Director of a CASA, was mistaken in evidence to the Committee regarding instructions provided by an operator, NJS, to a senior pilot, Captain Kolver, about the nature of a possible defect on the aircraft on which Captain Kolver later experienced exposure to fume contamination and subsequent incapacitation.1
6.13 This Committee notes that contamination of aircraft cabin air may conflict with the requirements of at least three civil aviation regulations;  CAR 48.0 1.4 and CAR 25.831: on cabin air quality and CAR 2 on major defects. Civil Aviation Advisory Publication (CAAP) 51-1 (O), counts (c) smoke, toxic or noxious fumes inside the aircraft as a major defect.
6.14 The Committee notes that the BASI/ATSB Occurrence Report of September 1999 expressed concern that the potential for future crew to become affected in flight due to exposure to odours in the cabin air environment constitutes a ‘safety deficiency’. The Committee notes further the evidence provided by the airlines, the manufacturer and CASA that day to day safety of the aircraft is not in question. However, the reported occurrences, some of which are serious, provide an argument that CASA, the manufacturer and airlines have not yet provided a satisfactory solution to this question.
6.15 When questioned on the application of the civil aviation regulations, CASA told the Committee that: “what constitutes ‘harmful or hazardous’ is left up to other standards and generally is getting into the area of occupational health”.2
6.16 Mr Toller acknowledged that oil leaks did occur on the BAe 146, leaving the question open as to whether these occurrences conflict with the civil aviation regulations.3 Given emphasis of an explicit link between occupational health of pilots and the safety of the aircraft made by BASI/ATSB, several medical professionals and some pilots the Committee finds the response of CASA to this issue to be inadequate.
6.17 Four Australian pilots gave evidence to this inquiry detailing incidents in which they had been affected, by fumes entering the cockpit of the BAe 146. A serious incident of pilot incapacitation on a BAe 146 was reported in Sweden in November last year.
1 CASA, Evidence, 1 November 1999, p 40 2 CASA, Evidence, 1 November 1999, p 48 3 CASA, Evidence, 1 November 1999, p 42
6.18 By contrast, the Committee also notes the strong evidence of a tendency of pilots to under-report incidents of this nature. The Committee was told in evidence by operators and some pilots that the principal reasons for not reporting incidents relating to air quality are:
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reporting such incidents either to their employer or regulator may place an individual’s career at risk;
　
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