his being labeled with such a history or clinical
diagnosis.

In any one year, about 400 will appeal to the
Federal Air Surgeon. About 350 will petition
for an exemption and about 80 will petition the
NTSB. Of these 800, about 125 will eventually
be certified, most with operational limitations
and/or careful surveillance through special
follow-up medical examinations. The valid
question might be whether we are endangering
safety in denying so few. The answer has been
given. Limitations help control the level of risk
taken. We must tailor our decisions to the indi-
vidual. Individual rights and promotion of
aviation must be given practical consideration.
Livelihoods and investments in aircraft and
training are at stake. These factors would lead
us to take a look at the philosophy underlying
medical certification and standards.

Il. The Philosophy of Medical Certification
and Standards.

A. FAA Mission. The FAA mission is “to pro-
mote aviation while assuring safety in the air
and for those below”.

B. The Individual. Airmen share the medical
burden—F.AR 61.45 states in part:

“No person may act as pilot—when he has a
known physical deficiency or increase of a
known physical deficiency that would make
him unable to meet the physical requirements
of his current medical certificate.”

C. Medical Criterion. The primary criterion is
sudden, unpredictable incapacitation, We are
most interested in those organ systems most
likely to be associated with incapacitation—the
special senses, the cardiovascular system, the
nervous system and the respiratory system. It is
sometimes forgotten that poor judgment can be
incapacitating.

Many everyday diseases will react quite dif-
ferently with altitude. There can be subtle and
cumulative effects from altitude, alcohol, tobacco,
and mild emphysema. Special emphasis is ob-
viously placed upon arteriosclerotic heart disease,
hypertension, diabetes, epilepsy, mental disorders
and indiscriminate use of drugs and alcohol.
Medication is of importance not solely because of
incapacitating side effects. Its use may indicate
significant underlying pathology. At the same

time that the drug treats, it may make it more
difficult to ascertain the stage of the disease
process by suppression of clinical signs and
symptoms. One aim is to try to correlate
pathology and its treatment to performance.
This refers not only to motor skills, but also to
judgment. Early incipient disorders as of the
personality provide a hearty challenge to all
examiners,

D. Levels of Concern. As with drivers’ licenses,
we consider flying a privilege and not a right.
There is ingrained in our society the concept of
individual rights, and a voluntary exposure to
risk is highly valued as one of those rights. In
accepting the right of the individual to incur
personal risk, this right must be balanced against
society’s interest in the safety of the individual,
and even more against the overriding considera-
tions that limit the individual’s right to incur
risk when the exercise of that right creates a
risk for others. It is the latter consideration of
risk to others that disposes organized society to
consider activities as flying or driving to be a
privilege and not an incontestable right of the
individual. On the other hand, if performance
is demonstrated to be adequate, we feel that the
individual’s personal risk is by and large the
individual’s own decision. The paraplegic who
flies modified aircraft and who has demonstrated
his capabilities is not likely to be suddenly in-
capacitated due to his paraplegia. However, he
may run a high personal risk if he is subjected
to fire following an unavoidable non-fatal acci-
dent.

There are other levels of concern. In carrying
out the statutory safety responsibilities, the FAA
recognizes that society’s interests in safety are
diverse, the range and intensity of interest de-
pending upon the individual’s relationship to air
transportation :

1. People who pilot aircraft and people who
do not;

2. People who are pilots and those who are
passengers ;

3. Those who fly and those on the ground
whose person or property may be affected by
aircraft operations.

‘There are also the incongruities some have
labeled as the “gore factor”. Even the low inci-
dence and crash rate in common carriers elicits
a much greater expression of public concern than





writing minimal medical regulations where we
attempt to regulate as little as possible, consistent
with the mission of safety. Considerable pro-
fessional judgment is necessarily involved.

B. The Origin of our Standards Lies Largely
in Empiricism. On leaving the development of
new standards and looking to their earliest ori-
gins, we note that our first aeromedical standards
of 1926, under the Bureau of Air Commerce,
were an outgrowth of military standards. Back
in World War I many of those rejected from the
infantry became pilots. It was soon obvious
that the accident rate of those airmen with physi-
cal defects was much higher than the rate of
those without defects. This realization led to
the first medical standards for pilots and the
development of aviation medicine as a specialty.

No. one had prior experience and the first
standards by and large were arbitrary or geared
to the equipment and type of flying—goggles
and open-cockpit aircraft. In the beginning
goggles could not be ground to prescription, and
vision had to be normal without correction. The
standards were fairly rigid, and, when one was
grounded, there were no established avenues of
appeal. The standards remained much the same
for years. However, with the advent of the
FAA, a new philosophy concerning civil aero-
medical standards became apparent. As experi-
ence accumulated, it was determined that for
some deficiencies pilots could perform safely—
as through use of glasses or special training.
Certain standards were relaxed, waivers were
issued and an appeals system was established.

The military continues to use the same air-
space, same Air Traffic Control system, and some-
times, the same airports. However, military
aviation is mission-oriented. It does not foster
many of the individual freedoms which charac-
terize civil aviation and which are reflected in
our standards. While our earlier rules were
founded largely in empiricism, we are now enter-
ing a different phase. The modern tools of data
analysis are being applied to the certification
system to better determine precisely what condi-
tions appear to be most closely associated with
accidents.

C. The Standards are not Detailed. At a given
general physical examination, there are almost
no limits to historical detail or to the number of
tests that might be employed. The procedures

chosen will depend upon exercise of clinical judg-
ment. On the other hand a good physical exam-
ination will be much the same regardless of
purpose. Our minimal medical regulations, like
a good screening physical examination, must be
directed toward those relatively few areas where
discovery of disease or risk to safety would. be
more likely. Such regulations give more room
to individualize. This is essential to good medi-
cal practice. It would be improper to treat each
disease or condition the same way every time.
It would be impractical to address the regula-
tions to each disease and its variable manifesta-
tions. The regulations required will depend
upon how effectively each Aviation Medical
Examiner exercises his options—how well the
certification system operates. The greater the
reliability, the fewer the standards that are
needed.

D. The Standards Must be Applied to Docu-
mented Medical Evidence. We realize that in
the daily practice of medicine, practical limita-
tions and compromises in data accumulation and
interpretation will lead to some professional
differences of opinion. Further, there is a funda-
mental difference between private practice of
medicine, where physician-patient relationships
are paramount, and the practice of regulatory
medicine, where what is in the public interest
must be the foremost consideration. It is often
because this fundamental difference is not ap-
preciated by airmen or physicians that misunder-
standings arise between equally dedicated and
competent physicians. Basic to both practices
is the fact that we have to depend upon what the
individual reveals by history and what is found
on ‘examination.

Many pilots share a basic mistrust of flight
surgeons and AMEs. They are required to
undergo a physical examination at regular inter-
vals, to pay for something they often do not
want or think unnecessary. AMEs serve as a
threat to their careers as pilots or the pleasure
or the investments they have in flying. But the
AME also serves as an influence in the formation
or suppression of these attitudes. Knowing they
exist, we can be more alert to the evasiveness of
some applicants. A carefully documented his-
tory and examination is fundamental to the re-
liability of the certification system and in
assuring, as best we can, safety. Without re-
liable medical information obtained from a



the much larger number of persons who die as
the result of accidents in the very active private
sector. Our society accepts the concept that
those holding out their services to the public
will be held to a higher standard of care. This
concept is especially meaningful in aviation
where the passenger has neither choice nor bar-
gaining power in selecting the particular air-
craft, the crew, or the flight path for his trip.
The Federal Aviation Act of 1958 directs us to
give full consideration, in issuing certificates and
prescribing standards, to the duty resting upon
air carriers to perform their services with the
highest possible degree of safety. Expecting a
higher degree of safety, the public assumes that
there is less risk than in the private sector and
is less forgiving of lapses.

III. Limitations of the System.

With this background of philosophy, how
does the agency go about promulgating safety
rules, regulations or standards?

A. The Legislative Basis for Medical Standards.
The Federal Aviation Act makes it clear that our
mission is to promote safety of flight by prescrib-
ing minimum standards governing the design,
materials, workmanship, construction and _per-
formance of aircraft and to issue airman certifi-
cates to those individuals who demonstrate their
qualifications to exercise the privileges of the
certificate sought or held. The Act does not
address itself to specifics of minimum standards
but does direct and serves as the administrative
authority to establish standards.

The Administrative Procedures Act outlines
rather specific procedures that must be followed
by all regulatory agencies. It is the rules for
rule makers. It assures that the public, in gen-
eral, and those being regulated, in particular,
get a fair and legal “shake” and have their say
in court. This Act also accords any interested
person the right to petition for issuance, amend-
ment or repeal of any rule.

Further, the Administrator of the FAA pre-
scribes, in the form of an agency order, those
policies and procedures to be followed in rule
making. This order assures that those subject
to Federal Aviation Regulations are consulted
and that the public has opportunity to partici-
pate in rulemaking. This is not to say that the
responsibility for rulemaking is passed to others

or that regulations are adopted by popular vote.
Rules are developed by people who have a statu-
tory responsibility for representing the public
interest.

Finally, all rules must stand the tests of re-
view by the courts. They must be within the
statutory power of the agency. They must not
infringe upon constitutional rights, must not be
arbitrary or capricious and must not abuse the
discretionary authority. They must be support-
able by substantial evidence.

The role of the Office of Aviation Medicine in
air safety is predominately a regulatory one.
In prescribing reasonable minimal medical
standards, we practice regulatory medicine.
While this has traditionally been accepted as our
role, it has been accepted by some with reluct-
ance and continued questioning since decisions
in medicine are often based on highly-skilled
intuition. Being judgmental they cannot be re-
duced to an equation or practiced by the num-
bers.

Yet, the need for medical standards is obvious.
The uncontrolled diabetic or epileptic has no
role in the safe operation of aircraft. On the
other hand, when criteria are set, when lines are
drawn, they are seldom irrevocable and hope-
fully never completely arbitrary. While our
rules are not made to be broken, when individual
consideration is given to applicants, some will
be waivered. The only stipulation is that the
Federal Air Surgeon feels that the final deci-
sions concerning certain conditions should be
made by those who are in the full-time practice
of aviation medicine and who have the ultimate
responsibility for ensuring safety.

Before-leaving the subject of rule development
or genesis, a few short words should be said
about cost-benefits and safety. It may seem
crass to some to speak of costs in considering
safety. Yet, in the real world such considera-
tions must be made. On one hand the acceptance
of calculated risks is a part of our general atti-
tude toward life. On the other hand, a goal of
absolute safety would impose economically in-
tolerable expenditures. We must seek and main-
tain a level of safety obtainable with reasonable
resources which is in balance with cost and ef-
ficiency. Achieving this objective requires the
development of criteria and methods aimed at
improving air safety. This is most difficult in


that pertains to the FAA medical certification
system. Much could be stated about the man-
machine aspects of our total aviation system,
with the present imbalance of emphasis heavily
weighted toward the machines. Much could be
stated about the human maintenance concept as
applied to civilian airmen.

Of fundamental concern is that each AME
strive to practice good sound medicine consistent
with the state of the art and as related to the
special environment of flying. The basic premise
would also include the intent to consider the

individual and his total circumstance—medical,
social, and economic. Certification decisions
must be practical and hopefully without arbi-
trary preconceptions.

We all have responsibilities to the pilot and
his reliability; to the Air Traffic Controller who
at times must be the eyes and ears of the pilot;
to the passengers who would like to fly and, if it
should come to that, to survive any accident;
and even to the public who wants the service but
not the noise and pollution problems of the
modern day airport.



TECHNICAL REPORT STANDARD TITLE PAGE

1. Report No. 2. Government Accession No.

FAA-AM-71-25

3. Recipient's Catalog No.

4. Title and Subtitle

THE PHILOSOPHY AND LIMITATIONS OF FAA AEROMEDICAL
STANDARDS, POLICIES AND PROCEDURES

5. Report Date

June 1971

6. Performing Organization Code

7. Author! s)
Gordon K. Norwood, M.D.

8. Performing Organization Report No.

9. Performing Organization Name and Address
Office of Aviation Medicine
Federal Aviation Administration
800 Independence Avenue, S. W.

Washington, D. C. 20590

10. Work Unit No.

TI. Contract or Grant No.

12. Sponsoring Agency Name and Addrass
Office of Aviation Medicine
Federal Aviation Administration
800 Independence Avenue, S. W.
Washington, D. C. 20590

13. Type of Report and Period Covered

OAM Report

14. Sponsoring Agency Code

15. Supplementary Notes

16. Abstract

Designated Aviation Medical Examiners need available basic information
concerning the FAA medical certification system, the philosophy which
underlies standards, policy and procedures, and certain limitations of
the system. It is through such information that errors adverse to
safety can be forestalled and differences in opinions between equally
dedicated and knowledgeable physicians can be best averted. Regulatory
medicine must have orientation different from that in the private
practice of medicine. Insofar as these necessary differences and
limitations are recognized, the FAA mission of safety and promotion
of aviation should be enhanced by a more effective and equitable system
of medical certification,

17. Key Words 18. Distribution Statement

Availability is unlimited. Document
may be released to the National Tech-
nical Information Service, Springfield,

Standards (Aeromedical)
Examination (Aeromedical)
Training (Aviation medical

examiners) Virginia 22151, for sale to the public.
19. Security Classif. (of this report) WD. Security Classif, (of this page) Zi. No, of Pages | 22, Price
Unclassified Unclassified 7 $3.00

Form DOT F 1700.7 (8-69)



conscientious airman by a thorough physician,
the medical standards on the printed page are
indeed impotent. The certification decision made
must be consistent with this evidence in the
written record of the individual. This places
the burden of proof upon the individual and
upon his consultant physician. Unfortunately,
for every pilot who knows and conceals a severe
condition, somewhere there is a physician who
knows and keeps back the information by omis-
sion or, rarely, by commission.

Flight instructors commonly write on behalf
of applicants, confusing skill and knowledge
with health factors. However, these comments
are useful, especially in consideration of any
functional limitations. Physicians occasionally
express strong opinions about the eligibility of
an airman with pathology, pathology that the
physicians would normally consider outside the
range of their expertise. They argue:

1, As examining physicians, we are in the best
position to know.

2. You of FAA make arm-chair decisions.

We agree, but contend that there are other
factors:

1. We often obtain specialty reports unbe-
known to the physician.

2. The specialist in aviation medicine may

know of factors that the busy practitioner may"

not have considered.

3. Extensive medical records may be on file
with the FAA that were not available to the
examining physician.

4, Every effort is made to take into account
the limitations imposed by a strictly paper op-
eration.

5. When in doubt, the agency will often offer
its own facilities for additional evaluation.

It is wise to keep the channels of communica-
tion open and to confer with the Regional Flight
Surgeon or with the Aeromedical Certification
Branch in Oklahoma City. When in doubt as
to what to do, the AME should not issue. And
one final word as relates to differences of opinion.
While the FAA usually has no objection to the
AME testifying in behalf of his pilot patient,
caution should be exercised in examining an air-
man in order to qualify to give testimony in
litigation against the FAA. This may raise
questions as to conflict of interest.

E. The Need for Education. In looking at the
pitfalls and limitations of rules, it is understand-
able that education is preferred to regulation.
The FAA has neither the inclination nor the
manpower to keep America’s civilian pilots under
perennial surveillance. Much will depend upon
the knowledge and honesty of the individual
pilot. He should be indoctrinated to the phys-
iological consequences of illness, fatigue, drugs
and alcohol. Questions related to such knowl-
edge are now included in most of the written
FAA pilot examinations. Also, formal phys-
iological lectures and chamber rides are available
to pilots for a minimal fee.

There is a continuing need for AME education
also. Several seminars are held each year in
locations scattered throughout the contiguous
states. Longer, more advanced seminars are
held at the Civil Aeromedical Institute (CAMI)
in Oklahoma City and offer AMEs opportunity
for physiological training and chamber rides.

While there have been military schools of
aviation medicine for many years the first resi-
dency program for comparable civilian training
was established at Ohio State University in 1958.
A similar program was started by the University
of Oklahoma in cooperation with the FAA at
CAMI in 1967, AMEs are also provided with
further assistance through the Guide for Avia-
tion Medical Examiners. The Guide and semi-
nars are designed to assist in using a set of
regulations that allow latitude in interpretation.

IV. Summary.

The medical certification system has been
sketched to explain the role of the AME and
processing of applications by the FAA. The
overall effects of the system have been protrayed
to reflect the rather liberal modes of appeal avail-
able to the present-day airman. To better under-
stand these effects, the philosophy of certification
and standards was reviewed. While incapacita-
tion is of primary concern to safety, promotion
of aviation leads to other considerations to in-
clude individual rights, levels of concern, and
differing responsibilities.

In considering system limitations, the manner
in which new regulations are developed, the
empirical origins of our regulations, their brevity,
the need for documentation and education were
each touched upon. Much has not been covered


administration, and AME failure would mean
system failure. In the real world a system re-
quired by law also requires control, yet some
states define physicians as anyone in the healing
arts—to include homeopaths and faith healers.
The designation system overcoines these prob-
lems.

Unfortunately, it is also true that while many
physicians have no special interests or knowledge
in the medical aspects of flying, all physicians
have at least one pilot as a patient, a friend who
is a pilot, or patients who are passengers in the
air transport system. It is indeed unfortunate
when such a physician unknowingly prescribes
a certain course of therapy, perhaps surgery,
that is one of several alternatives and, in making
the choice, takes away the career of his pilot
patient.

The designated AME has been authorized or
empowered to issue medical certificates for the
FAA. These certificates are, in effect, a legal
document. Having a valid medical certificate
can be of some legal consequence for any airman
involved in an accident or incident, for example,
the legality of his performing certain duties and
even the validity of his insurance. The certifi-
cates are also in the public domain and are a
matter of public record. The medical records
themselves are, of course, privileged.

C. Processing of Medical Applications, The
FAA reviews each AME report when submitted
to the Aeromedical Certification Branch in Okla-
home City. It is reviewed for completeness and
for conformation with agency policy and proce-
dures. Instead of an FAA physician reviewing
each AME report, the information from the
report is submitted to a computer for screening.
If the data fail the edits of the computer, the
report is flagged for manual review. Problems
that go beyond simple clerical errors are re-
ferred to an FAA physician. This physician
may write for additional information such as
hospital records, specialty examination, or medi-
cal flight testing. After all the information is
in, eligibility for medical certification is decided
and the computer record is updated, creating a
data bank for special studies. Since AME fail-
ure would mean system failure, the computer is
also used to periodically survey the work of all
AMEs to assure that each continues to strive to
maintain a high level of responsibility toward

safety by performing careful examinations and
issuing medical certificates in keeping with
agency standards, policies and procedures.

D. Appeals for Reconsideration. When FAA
physicians review the medical evidence of prob-
Jem cases, some will be completely cleared.
There are nine conditions that always require
denial: myocardial infarction, angina or other
evidence of coronary heart disease, psychosis,
character and behavior disorder manifested by
overt acts, epilepsy, disturbance of consciousness
without satisfactory medical explanation, drug
addiction, chronic alcoholism, and diabetes re-
quiring drugs. A pilot with a history or clinical
diagnosis of one of these conditions can only be
further considered through the special appeal
called a petition for exemption, provided for in
Part 11 of the Féderal Aviatien Regulations
(FARs).

Except for the nine specific conditions, the
medical standards contain a provision for special
issue of medical certificates by FAA full-time
medical personnel, provided for in FAR 67.19.
For this latter type of reconsideration, special
tests are often required. Some will be issued a
medical certificate with special restrictions or
limitations not authorized for use by AMEs.
The applicant may have to submit special follow-
up reports. He may be limited operationally as
by “Valid for Daylight Operations Only”. Use
of limitations allows certification of airmen not
otherwise possible and at the same time allows
control over the level of risk to safety. Less
than 1% will be denied, many being the new
airmen. New airmen comprise 28% of all ap-
plications, yet receive 50% of the denials.

Any airman who receives a final denial from
the FAA is advised that he may appeal to the
National Transportation Safety Board (N'TSB)
for a “rules of evidence” type of hearing to
determine if the regulations were properly ap-
plied. Parties are usually represented by legal
counsel. Testimony is presented to a hearing
examiner who subsequently issues his “Initial
Decision”. Either party may appeal this initial
decision to the Full Board. Here legal briefs are
prepared, but no further testimony is allowed.
For the airman who has suffered one of the nine
conditions previously named, an appeal to the
NTSB would serve no useful purpose unless the
airman is prepared to contest the propriety of


THE PHILOSOPHY AND LIMITATIONS OF FAA AEROMEDICAL
STANDARDS, POLICIES AND PROCEDURES

While basic aviation medicine is much the same
all over the world, there are at times some rather
large differences between Air Force, Army, Navy
and civil aviation medicine as to outlook, atti-
tudes or philosophy. It is germane that civilian
Aviation Medical Examiners (AMEs) be ap-
prised of some of the philosophy and system
idiosyncrasies if they are to provide fair and
equitable decisions as to the medical qualifications
of American civilian, airmen under those rules,
policies, guidelines and procedures promulgated
by the Federal Air Surgeon of the Federal Avia-
tion Administration.

In order to gain a perspective of the present-
day regulatory and certification system, three
aspects will be considered :

I. The certification system and its overall
effects.
II. Philosophy of medical certification and
standards.
III. Limitations of the system.

I. The Medical Certification System and Its
‘Overall Effects.

A. Basics. For those who have had relatively
little experience with the FAA, the following
will give a few of the basics as related to medical
certification of civilian airmen. Airmen are
pilots, certain other flight crewmembers and air
traffic controllers (ATCs). Pilot licenses are
issued based upon demonstrated skill, knowledge
and experience. These licenses are periodically
validated by obtaining a medical certificate:

1. Airline pilots (First Class) are medically
examined for the FAA every 6 months.

2. Other commercial airmen (Second Class)
are examined every 12 months.

8. Private and student pilots (Third Class)
are examined every 2 years.

In 1927, 4,200 medical certificates were issued
as compared with 490,000 in 1970—an average

of about 1,400 each day. Over 50,000 new air-
men.come into the system each year.

B. Aviation Medical Fuaminers (AMEs). Al
medical examinations are presently performed
by an AME. The airman pays the physician.
The FAA does not regulate fees other than by
asking that fees be commensurate with the going
rate in the community. There are over 7,000
AMEs (including 700 military and 300 inter-
national), Forty percent are pilots and some
15% were formerly military flight surgeons.
The AME’s role is a unique one in that he is the
only representative of the FAA with whom every
pilot has a regular and required contact. He is
ideally situated to participate in grass roots
aviation and to contribute to ongoing airman
education. In practicing preventive medicine,
he can be instrumental in the early detection of
conditions which, when vigorously treated, will
preserve the careers, health and well being of
America’s airmen. We realize that the AME is
required to make line decisions:

1. He can be boxed in by pilots who are friends.

2. He often works under heavy workloads.

3. He may have limited information upon
which to base a decision.

4, He may have to deal with a pilot who is
evasive.

The designated AME system has worked well.
It provides a nucleus of aviation-oriented physi-
cians to perform careful examinations and to
recognize positive findings of significance to
aviation and public safety. The designation
system has made the FAA seminar program
feasible. This system was expanded in 1960 to
cover examinations for third-class certificates.
There are many reasons to designate, even if

‘some family physicians are excluded. Not all

family physicians want to do it. Many have no
special interest in medicine as related to flying.
No rule is any better than those charged with its