The evidence suggests that the incapacitation risk limits used by some states, particularly for cardiovascular disease, may be too restrictive when compared with other aircraft systems, and may adversely affect flight safety if experienced pilots are retired on overly stringent medical grounds.
by Ruwantissa Abeyratne
Death is the handmaiden of the pilot. Sometimes it comes by accident, sometimes by an act of God. ~ Albert Scott Crossfield ~ Medical Aspects
On 11 March 2023 an article in the U.S. Sun reported that “a British Airways pilot collapsed and died shortly before he was due to captain a packed jet. He had been preparing to fly from Cairo in Egypt to Heathrow Airport but had a heart attack in the crew’s hotel”.
Infrequently, one hears news of such a sad event: of sudden pilot incapacitation and death, both while flying an aircraft and otherwise. The World Health Organization reported in 2020 that “in 2019, the top 10 causes of death accounted for 55% of the 55.4 million deaths worldwide. The top global causes of death, in order of total number of lives lost, are associated with three broad topics: cardiovascular (ischaemic heart disease, stroke), respiratory (chronic obstructive pulmonary disease, lower respiratory infections) and neonatal conditions – which include birth asphyxia and birth trauma, neonatal sepsis and infections, and preterm birth complications”. Of this, cardiovascular disease is one of the most prominent in occurrence.
|A British Airways flight in Bordeaux, France [ File Photo Credit: Francais a Londres / Unsplash]|
Reports of pilot deaths, particularly while piloting aircraft, sometimes appear in media reports. Aviation, Space, and Environmental Medicine in 2012 recorded that “In 2004 there were 16,145 UK/JAR professional pilot license holders. Of the notified medical events, 36 presented as incapacitations; half were cardiac or cerebrovascular… There were four sudden deaths. The type of incapacitation varied with age. A male pilot in his 60s had 5 times the risk of incapacitation of a male pilot in his 40s. The annual incapacitation rate was 40/16,145 = 0.25%”.
BBC on 6 October 2015 reported that “Capt Michael Johnston, 57, was flying the plane with 147 passengers and five crew on board when he “passed away while at work”, as per the announcement of the airline. It was also revealed that he had double bypass surgery in 2006. Live Science of 27 September 2013 reported “ A pilot’s heart attack turned a United Airlines flight to Seattle into a dramatic scene where passengers attempted to save the pilot’s life, and one helped the co-pilot make an emergency landing in Boise, Idaho. The pilot died at the hospital, according to news reports. A midair heart attack is a scary scenario for sure, but the incident last night (Sept. 26) was unusual — heart attacks on flights are rare, and deaths are even rarer. A study of medical emergencies on five major airlines over a nearly three-year period showed that, of the 12,000 passengers who experienced some form of medical emergency during a flight, 0.3 percent (38 people) suffered cardiac arrest, in which the heart stops. The number who died over the study period was 31, according to the study, which was published in May in the New England Journal of Medicine”.
Aviation, Space and Environmental Medicine in March 2004 went on to say “The Chicago Convention in 1944 to standardize practices where uniformity would improve air navigation. In subsequent annexes to the original convention, the regulations that standardize personnel licensing and rules of the air were established that guide the medical requirements for pilots and aircrew today. After evaluation of available data and the potential risks at different times during a flight, ICAO set a goal of less than 1% risk of pilot incapacitation per year to guide the standards for medical examinations. Gastrointestinal issues, earaches, faintness, headache, and vertigo are the most common causes of incapacitation. Less common but more dangerous debilitations such as alcohol intoxication and sudden cardiac death have been implicated in mishaps, so screening for these risks carries high importance”.
Medical assessments carried out periodically on pilots are generally indicative of a pilot’s health but are not a guarantee against unforeseen health conditions.
The Aeromedical Office of the Airline Pilots Association reports that approximately 42 persons with rhythm disturbances contact the office annually. “Over one half of these persons have experienced syncopal episodes, with 5 to 10 in-cockpit syncopes per year. In a review of 102 syncopes over 5 years, less than half were attributed to ventricular arrhythmias. The majority of individuals with ventricular arrhythmias were permanently disqualified from flying, while most individuals with syncope believed to be bradyarrhythmic returned to flight after evaluation.
In Western Europe cardiovascular causes are the most common cause of loss of flying license, and the main cause for disqualification of pilots on medical grounds is cardiac arrhythmia – frequent ventricular premature beats, nonsustained VT, and paroxysmal atrial fibrillation were the most common problem arrhythmias
The evidence suggests that the incapacitation risk limits used by some states, particularly for cardiovascular disease, may be too restrictive when compared with other aircraft systems, and may adversely affect flight safety if experienced pilots are retired on overly stringent medical grounds. States using the 1% rule should consider relaxing the maximum acceptable sudden incapacitation risk to 2% per year”.
Legal and Regulatory Aspects
Legally, a pilot is in a special category: the same as a surgeon who is in charge of a person’s health and a can driver or bus driver in charge of a passenger’s security. Only, a pilot has to ensure the safety of hundreds of passengers all at once. Inasmuch as an airline would be guilty of negligent entrustment in handing over a plane full of passengers to an improperly licensed pilot, a pilot would be guilty of gross negligence – the highest form of negligence – if she jeopardizes the security and safety of the passenger in her charge.
The International Civil Aviation Organization addresses the issue of pilot’s health requirements under Annex 1 (Personnel Licensing) to the Chicago Convention of 1944 and provides further guidance in Procedures and requirements for the assessment of medical fitness which are contained in the Manual of Civil Aviation Medicine (Doc 8984). The International Air Transport Association (IATA) – the trade association of airlines – in its guidelines for flight crew requires the following: the absence of any medical condition or any suspected medical condition that may lead to any form of acute functional incapacity; the absence of any existing or former medical condition – acute, intermittent or chronic – that leads or may lead to any form of functional incapacity; the absence of any use of medication or substances which may impair functional capacity; minimal requirements to the necessary functions such as vision and hearing.
ICAO’s Annex 1 provides that, to satisfy the licensing requirements of medical fitness for the issue of various types of licenses, the applicant must meet certain appropriate medical requirements which are specified as three classes of Medical Assessment: Third Class: This is the most basic of the medical exams. It is required for those attempting to earn a student pilot license, recreational pilot license, and private pilot license.; Second Class: This one is required for anyone attempting to earn their commercial pilot license; First Class: A first class medical certificate is required in order to earn a airline transport pilot certificate.
The United States Federal Aviation Administration states that the main differences between these is how in depth the exam gets and how often you have to have it done. Much of the 3 tests are very similar although the first class medical exam is required to be done annually and includes an Electrocardiogram test if the applicant over the age of 40.
.Recommendation 126.96.36.199 of Annex 1 suggests that from 18 November 2010 States should apply, as part of their State safety programme, basic safety management principles to the medical assessment process of licence holders, that as a minimum include: routine analysis of in-flight incapacitation events and medical findings during medical assessments to identify areas of increased medical risk; and continuous re-evaluation of the medical assessment process to concentrate on identified areas of increased medical risk. This is followed by the recommendation that the period of validity of a Medical Assessment must begin on the day the medical examination is performed.
Here, validity means acceptance as truth or fact which would go towards recognizing a pilot’s suitability to fly an aircraft. An air carrier which wet leases an aircraft to another carrier would be guilty of negligent entrustment. So would any air carrier who employs pilots without checking if the pilot has a valid license.
Although we tend to glamourize those in aviation, from the confident captain to the glamourous cabin attendant even down to the humble chap in overalls who helps put he aircraft in the sky, they are all human, like the rest of us, subject to the vulnerabilities of humanity. When the I was working at ICAO I once had a meeting with an airline pilot who had been commanding a flight from Europe to Asia. His young first officer, just 38 years old, had been complaining about a pain in his back on the onward flight to Europe. He had informed the captain that it was “just a backache” and that he would get it checked by his brother who was practicing medicine in the city they were bound for. On the return flight the next day, over Zurich, the first officer had mentioned to the captain that his back ache had returned and that he would leave the flight deck for a few minutes to rest. A few minutes later a visibly upset cabin crew member had rushed into the flight deck and told the captain that the first officer had died.
The captain had been grief-stricken as the first officer was a good friend as well as a trusted colleague He had to fly alone the rest of the flight, with mental acuity and equanimity, and when I asked him how he managed the flight he said the worst feeling was the feeling of loneliness in the flight deck, which was overwhelming. The flight deck is a lonely place, even if there are two persons in it. Dr. Vivek Murthy, one time Surgeon General of the United States writing in the Harvard Business Review said: “Loneliness is a growing health epidemic. We live in the most technologically connected age in the history of civilization, yet rates of loneliness have doubled since the 1980s. Today, over 40% of adults in America report feeling lonely, and research suggests that the real number may well be higher”.
Heart attacks often come from nowhere, with no prior warning. However, what must be borne in mind, in the case of pilots is that pilots have negative factors that affect them that other professionals may not have, such as crew fatigue due to overscheduling, disturbance of sleep cycles caused by night flying and missing family events and celebrations, not to mention being away from home constantly. The overbearing loneliness factor may add to this.