I am in receipt of the second draft of the above report, made
available to me on 24 August. Whilst we are grateful for the
opportunity to make verbal comments to you, we are dismayed at the
time made available to us to do so, (i.e. by 9am Thursday August
25), especially given the time differences existing between me and
my colleagues in the United Kingdom. Given the importance of the
matter, I have set out below the substance of those comments, which
in the time available, we have formulated:
1. Bae's Previous comments
1.1 As you are aware, BAe submitted a detailed response to the
first draft of the report on 22 July 1999. Despite various
requests, we were not afforded the opportunity to discuss our
submission or the Report with you or any members of your team in
person. Given the nature of the Report and its recommendations, we
were surprised at this lack of consultation.
1.2 Similarly, we are also disappointed to note that the second
draft fails to take into account or address the majority of our
comments. In particular, it fails to answer the majority of the
points we raised in paragraphs 1, relating to flight crew
procedure, and 2, maintenance procedures, and why those procedures
were not followed.
1.3 According to the Report, the cause of the incident was oil
contamination of the air supply, (although there is no evidence of
the investigative basis for this finding). BAe accepts that from
time to time oil may leak into the air system. However, as we have
previously advised, when it became evident that this was occurring,
BAe in conjunction with Allied Signal in between 1991 and 1992,
developed modifications to reduce the frequency of such leaks. A
customer option of an oil filtration system was also introduced. No
mention is made of such modifications in your Report, or even
whether the aircraft in question was fitted with them. Given such
modifications, we consider that the safety recommendations in your
Report have already been complied with.
1.4 In any event, on the basis of the circumstances described in
the Report, the sole reason why this incident occurred is because
maintenance and operating procedures set out in the relevant MEL
were not followed. Had the defective air supply been correctly
labelled and isolated, the alleged oil contamination would not have
occurred (as is demonstrated by the fact that when the flight
continued the scheduled sectors with the number 4-engine bleed air
system turned off, these were completed without incident). Further,
the aircraft appears to have been operated for more than the
ten-day period set out (recommended) in the MEL. Given these facts,
we are surprised that these matters are not referred to in the
Report.
1.5 Similarly, basic aircrewmanship dictates that in this type of
situation oxygen masks should have been immediately donned. If this
had been the case, the affected crewmembers would not have been
prevented from properly carrying out their assigned duties, and
hence there should have been no threat to air safety. We do not
consider the comment "the crew did not consider the use of oxygen
masks necessary in the situation", to be an adequate explanation of
why this was not done.
2. Anecdotal Evidence
2.1 Much of the report relates to purely anecdotal evidence of
other incidents. You seek to link these with the incident under
investigation. While the nature of the Report makes it impossible
for us to comment on or assess the further incidents referred to,
it is our firm view that recent complaints regarding cabin air
quality arise from circumstances largely unconnected to oil
contamination and are not therefore relevant to the incident under
investigation. Yet, not only does *the Report refer extensively to
this anecdotal evidence, it fails to mention the additional
customer optional modifications that BAe has recently developed in
conjunction with Ansett Australia to address cabin air quality
issues and which are currently being embodied on Ansett's
fleet.
3. Failure to ICAO Practices
We have expressed our disappointment at your refusal to have a
meeting with us to discuss this Report. We also understand that you
failed to follow ICAO guidelines as set out in Annex 13, in that
you failed to follow standard reporting layout and that you made no
format notification to the UK Air Investigation Board. We
understand that the AA1B have made separate representations to you
to that effect. We also are led to believe that, at no stage, did
you contact UK Civil Aviation Authority, the Design Authority for
the aircraft.
4. Conclusion
In summary, our position remains that we continue to disagree with
the substance or your Report. We again request the opportunity to
meet with you and your team to go through the Report in
detail.
