Jonathan Phillips

MB  BS  FRANZCP

Consultant Psychiatrist

19th March 2009

Opinion

It seems to me, in the current circumstances, that my principal task is to reconsider your psychopathology as it was during the period when you were employed as a pilot with Qantas Airways Limited, and more particularly to determine, on the basis of your medical history and a scientific understanding of your illness, whether your position as a first officer with Qantas has caused or contributed to your psychiatric problems. 

Whilst I will keep within my area of expertise, it will be necessary to reference your clinical status circa 1979/1980 against the wording within s26 of the Workers Compensation Act 1926, particularly s26(a) and s26(b), and also to reference your condition against the wording in s74 of the Workers Injury Management and Workers Compensation Act 1998. 

There should be little doubt that you have suffered anxiety spectrum symptoms intermittently over many years and symptoms predated your period of employment with Qantas.  The symptoms at the earlier time were probably mainly of phobic type.  I note particularly the history obtained by Dr White who identified you to have developed a fear of blood which began following the accidental shooting, and the presence of anxiety linked with a fear of entrapment which followed the immobilisation of your head at the time when you underwent a brain scan.  Additionally, Dr Williams advised that you had a number of phobias over a number of years which did not relate to flying. 

I believe it might reasonably be stated that you had a predisposition to develop anxiety spectrum symptoms before 1979, but your symptoms were more of a phobic type than reflecting an obsessive compulsive disorder. 

You accidentally struck yourself in the region of the left eyebrow with a hammer on 15 November 1973.  You have been described as suffering from a concussion at the time, which in essence is a low/middle grade closed head injury generally of relatively short duration.  You suffered headache following that incident.  Headache is a core symptom of concussion.  Dr Allsop assessed you within two months of the injury and did not find any physical abnormality.  He ordered a brain scan (type unstated) and the radiologist did not find you to have any abnormality.

On the basis of the above, it is highly unlikely that you would have suffered any continuing organic damage to your brain which would have led to longer-term physical and/or psychological problems.  I believe it is fanciful to consider that your accident on 15 November 1973 had any relationship with the obsessive compulsive disorder which became problematic in 1979.  Simply, a brain injury needs to be severe if it is to be associated with any substantive psychiatric disorder including obsessive compulsive disorder. 

Perhaps the best description of the onset of your obsessive compulsive disorder has been given by Dr White.  My colleague identified your symptoms as having commenced suddenly on 29 August 1979 whilst you were flying between Perth and Singapore.  A check captain was in the cockpit, and you were aware that he might ask you questions about safety procedures involving the aircraft.  You developed, totally unexpectedly, a preoccupation with a situation of loss of all generators with the onset of a compulsion to switch to cut-off.  This was sensed by you as being both irrational and dangerous and set in process substantive anxiety.  You immobilised your left arm in order not to act on the compulsion.  The experience occurred again on 30 August 1979 whilst you were flying between Singapore and Sydney.  You were so overborne by the experience on the second occasion, as to cause you to experience a powerful need to leave your seat.  I understand that you experienced similar excessive compulsive incidents with co-existing anxiety symptoms on later flights. 

I do not think that there should be dispute about your obsessive compulsive symptoms which began on 29 August 1979 at a time of relative stress, and in the course of your routine employment with Qantas as a first officer.  The obsessive compulsive incidents then took a life of their own, causing you increasing distress and leading ultimately to the end of your career. 

Additionally, it should be emphasised that your early phobic anxiety symptoms and your obsessive compulsive disorder represent different psychiatric conditions and must not be confused.  I accept, however, that you developed, in keeping with your early phobic anxiety symptoms, a more general state of anxiety.  This state would have reduced your psychological resilience and predisposed you to other psychiatric symptoms at times of stress, including the beginning of your obsessive compulsive disorder on 29 August 1979.

The fact that your obsessive compulsive disorder began in the course of your employment with Qantas is obvious.  But for your position as first officer, and concerns regarding possible questioning by the check captain, you probably would have not developed obsessive compulsive symptoms associated with loss of all generators.  However, I do not rule out the possibility (even probability) that you may later have developed an obsessive compulsive disorder in some unrelated stressful situation. 

For the sake of clarity, you met DSM criteria[1] for obsessive compulsive disorder from the time of onset of your then symptoms.  DSM III was coming into use at/around that time[2].  Circa 1979/1980, obsessive compulsive disorder was referred to either by that name or by the older name of obsessive compulsive neurosis.  Specifically, in keeping with DSM III R criteria, you met criterion A for the disorder (the presence of intrusive ego-alien thoughts relating to the situation of loss of all generators and the presence of a compulsion of a powerful and repetitive nature to begin a shut-down procedure); criterion B (your symptoms were of such significance at the time to interfere with your role as a pilot) and criterion C (exclusion of Tourette's disorder, schizophrenia, major depression, organic mental disorder).

You will note that the word neurosis was still used at the time.  A neurosis is best described as a disorder of the mind which is repetitive, obligatory, stereotyped and due to non-organic causes.  In many ways the word neurosis reflected a lack of understanding of the pathophysiology of the brain.  It is a term which has no usefulness at the present time and has been generally discarded.  The word neurosis has been dropped from DSM nosology.

Obsessive compulsive disorder is undoubtedly caused by an organic brain dysfunction.  High resolution brain scanning (particularly MRI, fMRI) demonstrates abnormalities in three separate brain areas, the orbital frontal cortex, the cingulate gyrus and the caudate nucleus (the latter two areas being deeper within the structure of the brain).  The initial trigger for obsessive compulsive disorder is within the orbital frontal cortex, which in turn makes connection with the deeper structures[3].  A person with obsessive compulsive disorder has virtually no control over their symptoms and actions.  This explains why traditional psychotherapy and behaviour therapy will lead at best to reduction only in the intensity of symptoms.   However there are minimally two psychotropic agents: clomipramine (tricyclic anti-depressant) and fluvoxamine (SSRI anti-depressant) which assist in the management of the disorder.

Let me now return to s26 of the Workers Compensation Act 1926 relating to causation of personal injury.  It is my firm opinion that s26(a) and s26(b) apply in your case.  Specifically under s26(a) your employment (practising safety procedures in your head whilst in the cockpit of a 747 aircraft, and in the presence of a check pilot) was a necessary and obvious point in the development on 29 August 1979 of your obsessive compulsive disorder.  Additionally s26(b) seems to apply, noting that even if you had relatively unformed obsessive compulsive symptoms at the time, or a vulnerability to the onset of obsessive compulsive symptoms, then events on 29 August 1979 would have aggravated, accelerated or exacerbated the problem. 

Further, I believe there is strong clinical data to challenge comments made about you in the Notice under s74 of the Workers Injury Management and Workers Compensation Act 1998, particularly that you did not suffer an injury linked with your employment which caused an incapacity for work.  Additionally, I do not believe there is evidence to demonstrate that you suffered from an obsessive compulsive disorder prior to your experiences in the 747 aircraft on 29 August 1979. 

Whilst you may have been predisposed to the onset of obsessive compulsive disorder by 1979, the nexus between events on 29 August 1979 and the onset of your disorder is absolute. 

In keeping with comments made in my email to you, I believe you had symptoms of obsessive compulsive disorder of sufficient intensity from 29 August 1979 to have made you a risk to passengers in your aircraft, a point reinforced in the report prepared by Dr Goldfinch where he makes mention of potential operational problems.

It is true that many people with obsessive compulsive disorder do not act on their compulsions.  However some do.  A compulsion to carry out an action which could lead to an air disaster should have been taken seriously by Qantas.  Simply, there is a great difference between a compulsion with potential to cause danger to substantial numbers of other persons, and a personal compulsion which would not affect those around you or the public more generally.

I have reconsidered my 2001 report.  My opinion in that report remains unaltered.  The 2001 report and this document will best be read together.

Yours faithfully

JONATHAN PHILLIPS

Clinical Associate Professor