Davina Tavener

Dear Mr. Walsh, Iam writing to you in relation to your letter to Hated 3rd July 2015,regarding your Report concerning the death of Davina Travener on the 1st November 2014. Thank you for sharing your Report with the IAA and we share your desire to prevent further deaths under any circumstance where it is feasible to do so. With regard to the carriage of defibrillators (AED) on passenger aircraft, I can confirm the following is the current situation with regard to Irish Air Operator Certificate (AOC) holders: IRISH CAT INFORMATION REGARDING AED AND AIRCRAFT OPERATORS TYPES Aer Lingus A330 aircraft (Predominantly longhaul ops) AED carried A319/A320/A321 (shorthaul ops) No AED carried currently but plans are in progress to fit all shorthaul aircraft with AEDs in the near future Air Contractors B757 (longhaul ops) AED carried B737-300 shorthaul ops)~AED carried Cityjet Avro RJ-85 shorthaul ops- AED carried Norwegian Intl B737-800 (shorthaul ops _ AED carried Ryanair B737-800 (shorthaul ops) No AED carried Stobart Air ATR 42 & ATR 72 shorthaul @ps) No AED carried Bord StiurthoiriBoard of Dlrectors Oitig Chlaraithe: Registerod Offico: Anna Nolan (Cathaoirleach/Chairman): Foirgneamh na hAmanna, 11-12 Sraid D'Olier The Times Builaing; 11-12 D Olier Street Eamonn Brennan (Priomhfheidhmeannach Chief Executive). Balle Atha Cliath 2, Eire Dublin 2. Ireland Marie Bradley, Ernie Donnelly, Pascal Fitzgerald , Uimhir Chlaraithe; 211082. Ait Chlarailhe: Eire Registered No. 211082. Regislered in Ireland QuALITY Basil Geoghegan, Michael Noron, Kevin O'Driscoll Cuideachla Dlteanais Theoranta A Limited Liability Company S0 9001.20 NSAI Certif < 1 803

AII AOC holders are in full compliance with the recommendations of European Aviation Safety Agency (EASA) and International Civil Aviation Organisation (ICAO): The following are observations EASA and ICAO in regards to carrying defibrillators on board: EASA: Regulation (EU) No 965/2012 on Air Operations, Annex IV (Part CAT) In the AMCs to the Regulation (EU) No 965/2012 on Air Operations (available here), it is recommended, for commercial air transport operations, to carry an automatic external defibrillator on aeroplanes required to carry an emergency medical kit (those having a passenger seating configuration of more than 30 seats when any point on the planned route is more than 60 minutes flying time at normal cruising speed from an aerodrome at which qualified medical assistance could be expected to be available) under certain conditions. Namely the acceptable means of compliance to the rule concerned (CAT.IDEA.225); the content of the Emergency Medical Kit; recommend operators to determine through risk assessment the need to the defibrillator; So there is no strict requirement for operators, but only a recommendation based on the result ofa risk assessment: 2 ICAO: The above is in line with the current ICAO Annex 6 recommendation, which reads as follows: ATTACHMENT B. MEDICAL SUPPLIES Supplementary to Chapter 6,6.2.2 a)
1.2 Based on the limited available evidence, only a very small number of passengers are likely to benefit from the carriage ofautomated external defibrillators (AED) on aeroplanes However, many operators carry them because they offer the only effective treatment for cardiac fibrillation The likelihood of use,and therefore of potential benefit to a passenger; is greatest in aircraft carrying a number of passengers, over long duration sector lengths The carriage of AEDs should be determined by operators on the basis ofa risk assessment taking into account the particular needs ofthe operation: Regarding the of AED's on short-haul aircraft; there may be very little impact on the actual overall statistics Notwithstanding that; I can confirm that the Chief Executive of the IAA has written to the Chief Executive of Ryanair on the matter. Further to that correspondence, it is our understanding that Ryanair are now positively reviewing the from listing " carry large carriage

carriage on their and that they will make a decision shortly. If this were to come to pass, it would be on a voluntary basis and is beyond the current EASA ICAO requirements. Finally, on behalf of the Irish Aviation Authority, [ wish to extend my sympathies to the family of Ms. Tavener for the sad loss of their loved one.

Dear Mr Walsh, Thank you for sharing your concerns with us about provision of emergency medical equipment on-board passenger aircraft operating under EU legislation, in particular; airway adjuncts, suction equipment; bag-valve mask equipment and defibrillators. would like to clarify the particular status of the European Aviation Safety Agency (EASA) As you may be aware, EASA is governed by Regulation (EC) 216/2008 which sets our tasks and responsibilities in the area of aviation safety: EASA's legal status, as an Agency of the European Union, the latter being an international organisation, is further set out in Protocol (No 7) on the Privileges and Immunities of the European Union to the Treaty on the Functioning of the European Union: In light of this, the Agency is not subject to the national rules and procedures of a Member State, such as the Coroners and Justice Act 2009, the Corners (Investigations) Regulations 2013 and any ensuing instructions derived therefrom: Notwithstanding the above, have given due consideration to your concerns, also taking into account the circumstances of the tragic event that triggered your request_ subject of defibrillators has been debated at length over recent years within the international aviation community, and the International Civil Aviation Organisation and the EU have so far concluded not to mandate their carriage. However, do see a lot of merit in your proposal in support of the health and welfare of the travelling public; Technological advancements, with automated external defibrillators becoming smaller, lighter, more economic, and, more importantly, easier and safer to use; coupled with changing passenger demographics, reinforces the opportunity for the issue to be revisited. We will therefore engage with our Member States to reconsider situation through analysis of available data. We will Iaunch a first discussion on this matter at our next meeting with Member Postal ddress: Postfach 10 12 53, Tel:: +49 221 89990 2000 2500 50452 Cologne, Germany E-mail: patrick ky@easa europa eu Visiting address: Ottoplatz Web: wwweasa europa,eu M eensy 0l the European Union TE GEN.00104-002 50679 Cologne; Germany ISO 9001 Certified of 2 July the The the Fax; Page

EASA European Avialion Safcly Agency States' representatives participating in the air operations thematic advisory group which is scheduled to take place on 9 September 2015.

Dear Mr Walsh DAVINA TAVENER DECEASED refer to your letter of 3 July to Dame Deirdre Hutton, on whose behalf am responding: must apologise for your 28 August deadline_ and the need for Jo chase this up. Your letter referred to your report to prevent future deaths under paragraph 7, schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. The report followed upon the conclusion of the Inquest;, on 15 June, into the death of Davina Tavener Your report raised a number of Matters of Concern from the Inquest evidence and you requested the CAA, the Irish Aviation Authority and the European Aviation Safety Authority (EASA) to consider those concerns and carry out a review with regard to the following: The Regulations in relation to mandatory and compulsory medical equipment to be carried on aircraft operating both within Europe and out of bases in Europe; 2 The medical equipment to be carried on aircraft as a mandatory and compulsory provision with specific reference to airway adjuncts, suction equipment; bag-valve-mask equipment and a defibrillator; and 3 The compliance by airlines under the control of the competent national authority , namely the Civil Aviation Authority in the United Kingdom and the Irish Aviation Authority in Ireland, to address any changes in the mandatory and compulsory provision of medical equipment to be carried on aircraft. Under the heading "Action should be taken" at section 6 of the Report; you state your opinion that urgent action should be taken to prevent future deaths, and your belief that and my organisation have the power to take such action. Our response is required t0 contain details of action taken or proposed to be taken, setting out the timetable for action, or otherwise explain why no action is proposed. Civil Aviation Authority CAA House K5 45-59 Kingsway London WCZB 6TE

Direct Line 7453 6174 Fax 020 7453 6175 david stoplar@caa.co.uk missing 020

It should be noted, as recorded at section 5(1) of your report on the evidence given at the Inquest that EASA is responsible for the regulations relating to equipment to be carried on aircraft operating in Europe, and that competent national authorities, such as the CAA and IAA, are responsible for oversight of compliance. Those regulations do not require aircraft to carry the equipment in question and the minimum requirement is to carry the equipment that Ryanair carried on subject flight: It was accepted that Ryanair was operating within the regulations on that flight: The details of the regulatory framework were set out in response of 10 March 2015 to your request for information for the Inquest, so will not be repeated here. In terms of possible changes to the current regulations on compulsory carriage of defibrillators; the CAA's current view as set out on its Aviation Health Unit website , is that cases of sudden cardiac arrest are rare when compared to the number of passengers carried. The evidence from those airlines that have been carrying them on a voluntary basis is that although a few lives are saved, in most cases the use of a defibrillator is not successful. This is partly because some of the cases are not due to ventricular fibrillation (the most common cause of cardiac arrest) and therefore a defibrillator will not be able to restore a normal rhythm: Also even if a normal heart rhythm can be restored, the cause of the abnormal rhythm such as a heart attack cannot be treated until the person to hospital and this can take several hours Although defibrillators are now more commonly found in public places, they are not a legal requirement even in places where large numbers of people gather: There is no evidence that airline passengers are at increased risk of sudden cardiac arrest and most authorities do not consider that it would be justified to make it compulsory for all aircraft to carry defibrillators_ Some airlines do carry defibrillators on a voluntary basis particularly those operating on long haul sectors or mixed long haul and short haul sectors The EASA regulations require operators to consider carrying them, depending on the type of their operations and other factors, such as passenger demographics (age etc) In the case of an airline operating only short haul routes, with flight durations of typically up to 3-4 hours (but often much shorter), the likelihood of a passenger who was well at the time of boarding having a significant medical event during the flight;, let alone a cardiac arrest; is exceptionally small: Your report notes at Section 5(vi) that "the saving of a single life would justify the availability of equipment on all Aircraft for use as and when a medical emergency arises_ Tragic as this incident was, the mandating of any health or safety requirement will always be subject to some form of cost benefit analysis by whichever regulatory body seeks to introduce it. While defibrillators themselves are relatively cheap, there are significant additional costs associated with initial and continuation training for the crew in using them reliance cannot be placed on there being a trained health professional or first aider on board at the time of the incident- and of specialist expertise in advising on the defibrillator programme, particularly the review of incidents where the defibrillator has been applied. With reference to the request at Section 5(2)(i) and (ii) of your report; we consider that a change in EASA regulations to mandate the general carriage of this equipment would currently be difficult to justify. We acknowledge however the importance of keeping the evidence of such incidents under review, and sharing such information and data as we receive with our EASA colleagues. We also recognise that there is scope, given current voluntary carriage by some airlines, and EASA requirements to consider carriage, to further Iook at the efficacy and success rate where this occurs and whether other airlines should be challenged to take action voluntarily. We would propose therefore to raise this issue at the CAAindustry forum for such discussions, the Flight Operations Liaison Group. Here we could obtain an industry view on the issue, and in particular whether operators should review their risk assessments with regard to medical kits and defibrillators It would be for EASA to consider the need for any change in the Regulations which apply to EU operators and for ICAO to consider this in relation to non-European operators. In either case , this the very gets

would require significant international agreement that a change should be mandated; While the UK cannot act alone in terms of legal change, if, through working with industry it could be shown that there was an evidence based case for a change in the legislation, the CAA would support this With reference to Section 5(2)(ii) of your report; it would of course be CAA's role in the UK to ensure regulatory compliance with new legislative requirements