Royal Australian Air Force Firefighter Case File Review Report
Introduction
A review of Royal Australian Air Force (RAAF) firefighters’ Department of Veterans’ Affairs (DVA)
case files and Australian Defence Force (ADF) health records was undertaken in accordance with the
Terms of Reference at Enclosure 1.
The aims of the review were, in summary, to identify individual and/or trends in health conditions
arising in the target group which, based on current medical research, may not have previously been
recognised as being employment-related, and to make appropriate recommendations to DVA.
Background
Prior to the early 2000s, RAAF firefighters were exposed to an extensive variety of chemicals. In
addition to task-specific compounds such as firefighting foams and fire extinguisher agents,
flammable waste chemicals were frequently obtained from base workshops and elsewhere and,
together with fuels, burnt in pits, or in simulators during aircraft crash rescue training. Products
from the extensively studied F111 deseal/reseal programs were amongst those disposed of in this
manner at RAAF Base Amberley. Many such chemicals are known to be hazardous, with potential
adverse health effects ranging from minor skin and/or respiratory irritation to cancer. This situation
arose in the absence of effective occupational health and safety systems and practices, resulting in
the variable use of appropriate personal protective equipment, particularly respiratory devices, at
key stages of the burn processes.
Concerns have been expressed by current and former firefighters in relation to health problems
believed to have arisen from their employment, and some have directly attributed life-threatening
conditions, particularly cancers, to chemical exposures. This review is a component of a broader
investigative, research and analytical initiative intended to deliver an answer to the question of
whether RAAF firefighters have been harmed as a result of their service, and provide compensation
where appropriate.
Methodology
DVA case files and ADF health records of seventy-one current and former RAAF, Royal Australian
Navy (RAN) (two cases) and Australian Army (two cases) firefighters who had served at RAAF Base
Amberley during the periods of the F111 deseal/reseal programs were reviewed, and relevant data
extracted. These data included demographic and Service-related (military identification, duration of
service and postings) details, reported chemical exposure events, diagnosed health conditions and
claims outcomes. Latency periods for the onset of conditions were calculated.
Liaison was effected with Professor Tee Guidotti in relation to his medical research literature review
on the association between employment as a firefighter and the development of adverse health
conditions. His recommendations were applied to the review conclusions and recommendations.
Findings
Conditions
Five hundred and sixty-seven adverse health conditions (an average of eight per person) were
identified, distributed by general body systems with prevalence percentages as follows:
System
Number of conditions
Percentage of total
Musculoskeletal
Gastrointestinal
Skin
Ear, nose and throat
Psychiatric/psychological
Genitourinary
Neurological including eye
Endocrine and metabolic
Cardiovascular
Immunological /infectious/
haematological
Respiratory
Dental
Other
168
77
73
59
57
37
30
25
14
29.6
13.6
12.9
10.4
10.1
6.5
5.3
4.4
2.5
12
9
5
1
2.1
1.6
0.9
0.2
Overlap of a small number of conditions occurred in respect of body systems. In such cases,
conditions were recorded against principal systems.
The most common conditions in each system were:

Musculoskeletal – degenerative spine and joint diseases, fractures and
sprains;











Gastrointestinal – gastro-oesophageal reflux disease, irritable bowel
syndrome, polyps, diverticular disease, hernias, peptic ulcers and haemorrhoids;
Skin – solar-related damage including neoplasia, urticaria, seborrhoeic
dermatitis and infections;
Ear, nose and throat – sensorineural hearing loss with tinnitus and
obstructive sleep apnoea;
Psychiatric/psychological – depression, anxiety, post-traumatic stress
disorder and alcohol abuse;
Genitourinary – erectile dysfunction and prostate disorders;
Neurological including eye – headaches;
Endocrine and metabolic – hyperlipidaemia, gout and diabetes;
Cardiovascular – hypertension and ischaemic heart disease;
Immunological/infectious/haematological – no trend;
Respiratory – chronic obstructive airways disease; and
Dental – no trend.
Twelve potentially life-threatening conditions (excluding myocardial infarction, cerebrovascular
events and major depression) were identified, with calculated latency periods from commencement
of military service in brackets:
a.
Metastatic adenocarcinoma of the lung with suspected bowel origin
(47 years);
b.
c.
d.
e.
f.
g.
Bowel carcinoma (28 years);
Pancreatic carcinoma (47 years);
Motor neurone disease (unspecified);
Tongue squamous cell carcinoma (17 years);
Peripheral neuropathy, severe (12 years);
Prostate carcinoma (2) (27 and 34 years);
2
h.
i.
j.
k.
Parotid adenocarcinoma (36 years);
Thyroid carcinoma (13 years);
Non-Hodgkin’s lymphoma with Sjogren’s syndrome (21 years); and
Lung adenocarcinoma (41 years).
One myocardial infarction (20 year latency) was identified, as were two cerebrovascular events (31
and 37 year latencies) and three major depressions (23, 26 and 32 year latencies).
Exposure
The actual exposure of individuals to single or groups of chemicals was unable to be determined, as
no records were made of either the chemicals employed or the individuals engaged in the relevant
tasks. Sixteen exposure incidents were reported, with chemicals ranging from herbicides to battery
and/or unidentified fire fumes and variable exposure levels. However, no trend was noted. Using
durations of Service and postings as exposure proxies was also considered to be of limited value.
Based on reported practices, all firefighters’ initial, advanced and continuation training likely
involved similar exposures, with the exceptions of the F111 deseal/reseal waste products at RAAF
Base Amberley, and some lesser exposures at small bases due to reduced training frequency.
Nonetheless, for the individuals identified as having life-threatening conditions, posting locations
and durations were evaluated. These twelve individuals served for an average of 17.8 years (range
6-26) with an average posting duration at RAAF Base Amberley of 6.4 years (range 1-15). This was
not substantially different from the remainder of the cohort at 17.1 years (range 3-36) and 5.0 years
(range <1-20) respectively.
Test results and specialist assessments
Pathology, imaging and other test results were reviewed but not further considered as they were
consistent with the identified health conditions.
Specialist assessments were also consistent with the conditions, albeit not necessarily in the initial
stages, particularly in regard to complex diagnoses such as peripheral neuropathy and Sjogren’s
syndrome. Additionally, specialist opinions on the aetiology of diagnosed health conditions
appeared to have been made on the basis of individual histories and surmised associations without
the benefit of recourse to medical research and, in particular, epidemiological information on the
occupational cohort.
Claims
Four hundred and twelve claims were submitted, of which 68% (278) were accepted. The majority
of these involved common musculoskeletal, skin (solar keratosis and neoplasia), ear, nose and throat
(sensorineural hearing loss and tinnitus), psychiatric and gastrointestinal (colonic polyps, irritable
bowel syndrome and diverticular disease) conditions. Nine of the potentially life-threatening
conditions were accepted. All myocardial infarction and major depression conditions were
accepted. Several previously declined claims were accepted following repeated appeals.
The one hundred and thirty-four declined claims represented a wide spectrum of conditions,
including gastro-oesophageal reflux, obstructive sleep apnoea, diabetes, benign prostatic
hyperplasia, depression and anxiety, hernias, hypertension, minor skin conditions, gout and
fractures. Many of these conditions had been detected late in life and the principal issue underlying
non-acceptance appeared to be the lack of recognized relationships between the conditions and
service. Life-threatening conditions which were not accepted were thyroid carcinoma, one of the
two prostate carcinomas, and motor neurone disease.
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The remaining one hundred and fifty-five conditions did not appear to have been submitted as
claims. In general, these followed the pattern of declined claims and many were of a relatively
minor nature. Neither of the cerebrovascular event conditions was claimed.
Other
Accurate dates of onset of conditions were not always documented, consistent with the challenges
associated with the timing of patient presentations and the complexity of clinical diagnostic
processes. Accordingly, dates of onset for latency purposes were deemed to be those of the initial
recorded presentations unless confirmatory imaging, pathology or other test results were available.
Tobacco smoking prevalence, including duration and intensity, was unavailable due to incomplete
recording of smoking habit in the reviewed files. As tobacco smoking is a known cause of a range of
serious adverse health conditions, including cancers, its actual role as a confounder could not be
determined.
Complete health records were available for fifty-eight personnel, with condition-specific health
records available for the remainder. This was considered adequate for the purposes of the review.
Conclusions
General
The predominance of common musculoskeletal, skin and ear, nose and throat conditions (53% of the
total) is consistent with the inherent nature of firefighter duties, which include high physical
demands and exposure to outdoor and high noise environments. The prevalence and distribution of
psychiatric conditions (10% of the total) are consistent with both exposures to traumatic incidents
and, to some extent, the cohort demographic. Many other identified conditions, including
obstructive sleep apnoea, diverticular disease, haemorrhoids, gastro-oesophageal reflux disease,
diabetes, hypertension, ischaemic heart disease and benign prostatic hyperplasia are also principally
lifestyle and ageing-related, and occurred in line with community trends. These last are thus likely
to have tenuous relationships with military service.
The low prevalence of chronic respiratory conditions (less than 2%) was very surprising, in light of
known (albeit unquantified) smoke exposure associated with limited use of respiratory protection,
and likely prevalence of tobacco use.
Life-threatening conditions
The presence of twelve potentially life-threatening conditions, which are predominantly cancers, in a
sample size of seventy-one, requires detailed consideration.
Professor Guidotti’s report (Reference 1) and associated correspondence in relation to his medical
literature review (Reference 2) identify several relevant issues regarding the association between
employment as a firefighter and consequent adverse health conditions as follows:


Firefighters are exposed to hazardous chemicals
and substances associated with combustion, in particular carbon monoxide, cyanide,
polycyclic aromatic hydrocarbons (PAHs), benzene and fine particulate matter, all of which
are significant toxic agents for cardiovascular effects;
Significant chemicals for cancer risk are PAHs,
asbestos, benzene, 1,3 butadiene, trichloroethylene, dioxins and furans, and vinyl chloride;
formaldehyde may also be significant;
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




Additional exposure to diesel exhaust emissions,
combustion products from plastics and building materials, specific substances such as
polychlorinated biphenyl (PCB) compounds, and jet fuel may be significant;
The weight of current evidence is sufficient to
recommend causation for the following conditions:
o
myocardial infarction within 72 hours of response;
o
acute respiratory failure following toxic
inhalation;
o
asthma associated with intense exposure;
o
bladder cancer;
o
renal cancer;
o
testicular cancer;
o
lymphoma;
o
myelomas;
o
leukaemia;
o
brain cancers;
o
lung cancer in non-smokers;
o
mesothelioma;
o
lip cancer;
o
breast cancer in males;
o
amyotrophic lateral sclerosis;
o
noise-induced hearing loss; and
o
post-traumatic stress disorder and reactive
depression.
The weight of current evidence also suggests
causation, with qualification, for the following conditions:
o
accelerated lung function decline in non-smokers;
o
asthma, irritant-induced with impairment;
o
chronic obstructive airways disease in nonsmokers;
o
colon cancer;
o
melanoma;
o
myeloma;
o
parotid gland tumours;
o
nasal sinus cancer;
o
traumatic injury; and
o
musculoskeletal disorders.
Current evidence is insufficient to suggest
causation, with individual evaluation required, for the following conditions:
o
sarcoidosis;
o
thyroid cancer;
o
oesophageal cancer;
o
basal and squamous cell carcinomas;
o
laryngeal cancer;
o
prostate cancer before age sixty; and
o
infectious disease.
Current evidence also makes an association
unlikely for the following conditions:
o
prostate cancer after age sixty;
o
glomerulonephritis; and
o
infertility and birth defects.
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Substances present at the former RAAF Base Point Cook fire training area have been identified and
include the majority of the cancer risk chemicals (in one form or another) as listed above. It is likely
that these chemicals are also represented at former burn pits and fire training grounds at other
RAAF bases, including Amberley. Professor Guidotti’s recommendations are consistent with the
acceptance of five of the identified life-threatening conditions (metastatic adenocarcinoma of the
lung with suspected bowel origin, bowel carcinoma, parotid adenocarcinoma, non-Hodgkin’s
lymphoma with Sjogren’s syndrome and lung adenocarcinoma), albeit the last of these occurred in a
heavy smoker).
In accordance with subsection 7(2) of the Safety, Rehabilitation and Compensation Act 1988 (SRCA)
(Reference 3), thirty-one conditions have been listed as compensable for the F-111 deseal/reseal
and other fuel tank maintenance workers classified as Tier 1, 2 or 3 participants. The subjects of this
review are in the last of these classifications. Three groups of additional life-threatening conditions
are included in this list, which are peripheral neuropathy, spinal muscular atrophy and malignant
neoplasms, encompassing the remaining seven such identified conditions (peripheral neuropathy,
motor neurone disease and pancreatic, tongue squamous cell, prostate (2), and thyroid carcinomas).
No clusters or trends were identified in the life-threatening conditions. This may indicate that
exposures to chemicals which are or may be associated with adverse health conditions were
variable. Trends in other conditions are as stated in the Findings.
Other conditions
It is noteworthy that Professor Guidotti’s recommendations provide logical support for acceptance
of many of the musculoskeletal, hearing loss and psychiatric conditions which were identified. It is
also relevant that, with the exception of Professor Guidotti’s recommendations, the current global
medical literature is inadequate to credibly inform associations between employment as a firefighter
and the development of adverse health conditions.
Claims acceptance
Acceptance of claims was generally consistent and based on evaluation of the relationship between
the condition(s) and military service, with specialist opinions on causation (whether well- or illfounded) appearing to be influential in the decision process. However, the three potentially lifethreatening conditions which were not accepted (motor neurone disease, one prostate carcinoma
and a thyroid carcinoma) appear to have been eligible under the SRCA. In addition, it was apparent
that in the event of a claim being denied, the perseverance of the claimant in repeatedly and
vigorously appealing often resulted in eventual acceptance. Levels of compensation paid were not
specifically examined. These appeared to vary significantly in accordance with the application of
different legislative instruments and often subjective lifestyle assessments.
Discussion
Based on the available evidence, many RAAF firefighters who served prior to the implementation of
effective safe work practices developed multiple adverse health conditions due to the circumstances
of their employment. The identification of some predictable life-threatening conditions, but not
others, may be the result of a small sample size and variable exposures. The lack of precision in the
data means that we will never know the extent of any actual associations between work and illhealth.
The high profile of the health consequences of the F111 deseal/reseal programs and the inclusion of
RAAF firefighters in a potentially at-risk cohort is acknowledged. It was accordingly considered
unlikely that the significant diagnosed adverse health conditions of members of the reviewed group
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had not already been identified. Nonetheless, several of the conditions had not been the subject of
claims to DVA. The reasons for this are unknown, however, as previously stated, most such
conditions were relatively minor in nature.
The limitations identified during the course of the review, with the exception of chemical exposure
details and tobacco smoking prevalence, as stated in the Findings section, were not considered to
have substantially impacted on its utility.
The performance of additional analysis on commonly occurring non life-threatening conditions,
particularly with respect to latency periods, was considered but not pursued as this would not have
been consistent with the requirements of the Terms of Reference.
The de-identified file review database is at Enclosure 2 and the corresponding identification list is at
Enclosure 3, both of which are limited in distribution to appropriate authorities to facilitate
engagement of individuals impacted by this review.
Recommendations
1.
2.
3.
4.
5.
Liability for motor neurone disease, prostate
carcinoma and thyroid carcinoma should be accepted in accordance with the SRCA 7(2);
Professor Guidotti’s conclusions at Reference 1
should be incorporated into the claims determination process for military firefighters;
Advice should be provided to the individuals who
were subject to the review that, where appropriate, claims for the remainder of their
conditions should be submitted to DVA;
Reliance on specialist assessments in the claims
determination process should be limited to the specialists’ area(s) of expertise; and
Consideration should be given to routine
monitoring of the medical literature to ensure that any further associations between
employment as a firefighter and the development of adverse health conditions can be
identified.
Dr Graeme Peel AM, CSC, MBBS, MPH, DAvMed, FAFOEM, FAFPHM, FACAsM
Occupational Physician
Group Captain (RAAF Specialist Reserve)
08 February 2014
Enclosures:
1.
File Review
2.
distribution)
3.
distribution)
Terms of Reference – Firefighter Case Study Case
File Review Database (de-identified, limited
File Review Database identification list (limited
References:
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1.
Health Risks and Occupation as a Firefighter, Tee
L. Guidotti, 8 January 2014.
2.
Personal communications Professor Tee Guidotti
and Dr Graeme Peel, November 2013-January 2014.
3.
Safety, Rehabilitation and Compensation Act 1988
(SRCA) subsection 7(2).
This review was conducted in accordance with the Services Agreement dated 5 September 2013, and
subsequent variations, between the Commonwealth of Australia and Peel Medical Pty Ltd.
Any correspondence in relation to this report should be addressed to:
Dr Graeme Peel
Peel Medical Pty Ltd
ACN 137426870
PO Box 404
The Gap Queensland 4061
Mobile: 0432638082
Email: gpeel@bigpond.net.au
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