5.20 British Aerospace was critical of the Occurrence Brief in relation to both how it was written and its content. British Aerospace’s submission dealing with the content of the Brief stated:
British Aerospace disagrees with the conclusions of the Occurrence Brief. In particular, its Safety Recommendations fail to take account of the modifications introduced both by BAe and the engine and APU manufacturers since the early 1990's specifically designed to address the issue of possible contamination of the cabin air supply.
On the basis of the circumstances described in the Occurrence Brief, this incident would not have occurred had the procedures set out in BAe's Master Minimum Equipment List … been applied to the known "defect" in the aircraft's bleed air system.
The Occurrence Brief refers to anecdotal reports of "health problems" suffered by flight and cabin crew of various Australian operators. … however, British Aerospace believes that recent complaints regarding cabin air quality on BAe 146 aircraft have largely no connection with the subject incident.17
5.21 British Aerospace also advised the Committee that, in relation to the specific matters relating to the aircraft’s configuration:
British Aerospace has expressed its disappointment to BASI regarding the procedures followed in the preparation of the Occurrence Brief and in particular the level of consultation afforded to it.
According to the Occurrence Brief, the cause of the incident was oil contamination of the cabin air supply due to a leaking oil seal.
The problem with the leaking oil seal was first noted by the operator on 17 June 1997, some 23 days before the incident.
Had the corresponding engine bleed air system been treated as inoperative, the provision of the MMEL would have required it to be isolated and placarded … Application of these procedures would have avoided any contamination of the air supply. The Occurrence Brief makes no reference to this.
Once the contaminated air supply was isolated, the remaining sectors were flown without incident.
British Aerospace accepts that from time to time oil may leak into the cabin air system. However, between 1991 and 1992, when it became evident that this was an issue, British Aerospace in conjunction with AlliedSignal developed modifications to reduce the frequency of such leaks.
17 Submission 11B, British Aerospace, p 1
As part of the modifications an air filtration system was offered to the operators as a customer option. The Occurrence Brief makes no mention of whether air filters or other modifications had been installed on the aircraft in question.
5.22 In relation to matters affecting occupational health, British Aerospace noted:
The Occurrence Brief also refers to anecdotal reports of health problems alleged to have been suffered by flight and cabin crew of various Australian operators and suggests that there is a link between these and the incident under investigation. While the nature of the Occurrence Brief makes it impossible for British Aerospace to comment on or assess the details of any of these further incidents, it is British Aerospace's view that recent complaints regarding cabin air quality have largely arisen from circumstances unconnected to oil contamination and are therefore not relevant to the incident investigated by BASI. British Aerospace has in any event recently been working with Ansett to introduce a package of enhancements to improve the BAe 146 cabin environment … none of which are mentioned in the Occurrence Brief.18
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