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Acknowledgment

Appreciation is extended to Dr. Audie W. Davis, Manager, Aero-
medical Certification Branch, and Dr. Charles F. Booze, Jr.
Supervisor, Medical Statistical Section, Aeromedical Certification
Branch, for their valuable guidance, comments, and- suggestions
during the preparation of this study. The author also expresses
appreciation to Mrs. Leslie Downey and Ms. Mickey Loveless for
their assistance in the review and preparation of this study.

availability Codes
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the 36 denied for myocardial infarction, 6 were also denied for coronary
artery bypass surgery and 5 for coronary artery disease.

Eighteen pilots were denied for administrative reasons and had no
pathology code recorded on their medical, One hundred seventy-six were
denied for a single cause, 89 for 2 causes, and 13 for 3 causes. Approx
imately 8 percent of the denials studied have since reapplied and been
issued first-class medical certification.

The Air Line Pilots Association (ALPA) states that it is part of an
airline pilot's professional responsibility to recognize that any departure
from good health status represents a threat to flight safety (3). There-
fore, as suggested in the Orford-Carter report (6), pilots should be
encouraged to report symptoms of disease, particularly cardiovascular and
neuropsychiatric diseases. This requires education to the effect that
failure to report symptoms to “avoid losing their job" may actually
result in an unnecessary termination of their career.

This and other studies (1,3,4,5,6,7) support the need for airline medical
departments, their contract doctors, and/or AME's to be informed that the
maintenance of high standards of safety requires increasingly closer
cardiovascular supervision after pilots reach 45 years of age.

MARY

FAA medical certificate denial is minimal before aye 45 but increases
rapidly thereafter, with cardiovascular diseases responsible for | more than
half of this dramatic rise in incidence of disease.

The overall highest causes for denial by pathology series are:

(i) cardiovascular; (ii) neuropsychiatric, and (iii) the miscellaneous
category, which includes endocrinopathies, general systemic conditions,”
use of disqualifying medication, and denials for failure to provide
additional medical information, with annual rates per 1,000 active
pirots of 2.3, 1.3, and 1,1 respectively.

The highest causes for denial by specific pathology are:
(i) use of disqualifying medications (65 percent of these were also
denied due to cardiovascular pathology), (ii) myocardial infarction,
(ili) alcoholism, (iv) coronary artery disease, (v) hypertension
withnedication, and (vi) coronary artery bypass surgery. These six
specific causes account for almost 50 percent of all causes for denial.

Uniformly lower denial rates were found for the larger employersy
many of which have their own medical facilities.

On the basis of these and previous findings regarding airline pilots,

it is evident that maintenance of high standards of safety requires
increasingly closer cardiovascular supervision as these pilots grow older.

13


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Descriptive studies of airline pilot populations (1,3,4,5,6,7) have shown
the rate of medical disqualification to be minimal before the age of 45
years; But to increase rapidly thereaiter, with cardiovascular diseases
responsible for more that half of this dramatic rise in incidence of
disease after age 45. The Orford-Carter study (6) and many others have
alteady hasized. this problem. of aging pilots and the increased risk of
Cardjovascular. disease. Orford-Carter also concluded that between the ages
of 45 and. 60 years, detection of disease assumes far greater importance than
in a pilot's younger years. Lavernhe's opinion (5) was that the considerable
increase in coronary risk with age warrants examination particularly intended
to detect coronary disease among older pilots. Preston (7) and others
(1,3) found lower denial rates for airline pilots whose employers have their
own medical -departnentss ~

This study provides comprehensive data reflecting pertinent denial rates
with respect to the general and medical attributes of airline pilots denied
first-class FA\ medical certification during the 2-year period preceding
tuly 1, 1980. It also further explores the conclusions and findings of the
previous studies regarding medical disqualification of airline pilots.

METHODS AND SOURCE

The Aeromedical Certification Branch (AMCB) of the Civil Aeromedical
Institute is the central screening facility and repository within the FAA
for the collection, processing, adjudication, investigation, and analysis
of medical data generated by the secromedical certification and related
programs.

The AMCB's computerized medicai records provide historical data for
both daily screening of document input and for epidemiologic/research
purposes. This computer file contains the most recent medical application
for all pilots, whether issued, pending, or denied.

The airline pilot denial data were obtained from the computer file as
of July t, 1980, for a 2-year period preceding that date. The active air-
line pilot population as of December 31, 1978, was used for rate computaticn
and comparison.

Airline pilots were identified by the applicant's response to block
10 of the FAA medical application. The occupation of airline pilot -~-
defined as pilot for scheduled and nonscheduled airlines only -- inciudes
captain, copilot, and first and second officer with a first-class medical
certificate.

Nv


mone - meer a ey

CHARACTERISTICS OF MEDICALLY DISQUALIFIED
AIRLINE PILOTS

INTRODUCTION

Federal Aviation Regulations (FAR's) require that pilots for scheduled
and nonscheduled airlines possess a first-class médical certificate to
validate their air transport pilot certificate. Airline pilots are required
to cbtain a Federal Aviation Administration (FAA) medical examination at
6-month intervals and must meet specific requirements for a first-class
medical certificate as set forth in FAR 67.13 (b) through (f). J
re not met, the application for firsr-class certification
s denial catirésult from any of several levels of certification
réview within the FAA, from the aviation medical examiner (AME) to the
Federal Air Surgeon. _

At the time this study was conducted, Federal Aviation Regulations, Part
67, specified that a medical certificate would be denied if any applicant had
an established medical history or clinical diagnosis of any of the following
conditions:

lL. A personality disorder that is.severe enough to have
repeatedly manifested icself by overt acts.

2. A psychosis.

3. Alcoholisu.

4. Drug dependence.
5. Epilepsy.

6. A disturbance of consciousness without satisfactory medical
-explanation of the cause.

7. Myocardial infarction.

y5) Angina pectoris or other evidence of coronary disease.
:/ Angina p goron
9) Diabetes mellitus that requires insulin or any other hypoglycemic
2 Stes ypog}
drug for control. ~

The_above conditions represent the causes for a mandatory denial. A
general denial may be issued, under FAR Part 67, for any other organic,
functional or structural disease, defect or limitation that the Federal Air
Surgeon finds makes the applicant unable to safely perform the duties or
exercise the privileges of the airman certificate that he holds or for which
he is applying; or may reasonably be expected, within 2 years after the
finding, to make him unable to perform those duties or exercise those
privileges. These findings are based on the case history and the appropriate,
qualified, medical judgment relating to the condition involved.



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REFERENCES.

Booze, C.F., 1974. Characteristics of medically disqualified airman
applicants during calendar year 1971. FAA Office of Aviation Medicine
Report No. AM~74-5,

Dark, S., 1980. Characteristics of medically disqualified airman
applicants in calendar years 1977 and 1978. FAA Office of Aviation
Medicine Report No. AM-80~19.

Eighth Bethesda Conference of the American College of Cardiology,
Washington, D.C., April 25-26, 1975. ‘Cardiovascular problems
associated with aviation safety. FAA Office of Aviation Medicine
Report No. AM-73-38, .

Kidera, G.J., 1967. Clinical aspects of commercial aviation medicine.
JOURNAL OF THE AMERICAN MEVICAL ASSOCIATION, 201:242-246.

Lavernhe, J., J. Pasquet, and A. Mathivat, 1969. incidence of cardio~
vascular diseases among the flight deck personnel of an airline.
AEROSPACE MEDICINE, 40:62-63

Orford, R.R., E.T. Carter, 1976. Pre-employment and periodic physical
examination of airline pilots at the Mayo Clinic, 1939-1974.
AVIATION, SPACE, AND ENVIRONMENTAL MEDICINE. 47(2):180-184.

Preston, F.S., 1968. Twelve year survey of airline pilots.
AEROSPACE MEDICINE, 39:312~314.



AME. Deniai
General Denial

Federal Air Surgeon
Denial

Exemption Denial

Mandatory Denial

Administrative or
Legal Deniai

Exemption Issued -
Later Terminated

Denial for Failure to
Provide Additional
Information

(FAR 67.31)

Percent of Total Denials

Figure 1. Denied airline pilots by level of denial.


| we

distributed by

(2°) Defense Technical Information Center
g DEFENSE LOGISTICS AGENCY

Cameron Station - Alexandria, Virginia 22314

UNCLASSIFIED


Only aviation-connected employers are recorded.on the computer record,
Data on denials by these employers provide some interesting insight, even
though fraught with limitations that. make comparison difficult, i.e.,

small numbers substantially affect compar m. uf interest, however, is
that the larger employers, many of which have their own sedical facilities,
have uniformly Lower denial races than the smaller enplovers. Presten (7)
and others (1.3) found the same lower rates for larger airlines. Part

of this difference is undoubtedly due co the preventive medical programs of
the larger employers and their assumed association with other organizations
prevention and rehabilitation programs. Another part of the difference is
likewise due to early recognition and removal from flight status of these
pilots manifesting disease states (pathology) likely to result in denial and
the fact that the major airlines have a larger, more select, group of pilots
from which to choose when initially employed (see Table: I). :

Anqual—aye-specific denial rates increase to the hi
interval 55-59 (14.4 per 1,000 active airline pilots). © hy rate y
disqualification is minimal before the age of 45 years but increases rapi
thereafter (from a rate of 2.5 at the 40-44 axe interval to 3.8 at t
ageninterval)(see Figure 4). Of the 110 pilots denied in the, 55-59 ace sroup,
half (49 percent) were 58 or 59 years ot aye (23 percent were 39 when denied).
The mean aue_of. active (issued) airbine pilots is 41.0 years of ane. as compares
tod mean aye of 49.7 for denied airling pilots.

est rate 3

Observed in the age-cause-specific annual denial rates is a rapid increase
of cardiovascular denials after aye $5. Noth ; us Pou in the
25-29 and 30-34 age intervals; however, in the 35-39 y interval, aicebolism,
as a cause for denial, begins to be rerlected in the desial rat y the
49-44 age interval, alcoholism again the highest cause tor denial with
cardiovascular diseases (myocardial infarction and coronary artery ovpass
surgery) second. Cardiovascular causes for denial begin to increase rapidly
in the 45-49 age interval, with myocardial infaretion hic!
artery disease second; use of disqualifying medications third (about two~
thirds of these are directly related to cardiovascular disease); coronary
artery bypass surgery fourth; and alcoholism ranking fifth. Cardiovascular
diseases continue to increase and to represent the highest cause tor cenial
in age intervals 50-54 and 55-59 (see Table 1). ”

sl; coronary

The_overal1 highest causes for denial by pathology series are?
ardiovasculasy. (ii) neuropsychiatric; and (iii) the miscellaneous cate~
gory includes endocrinopathies, general systemic cuaditions, use of
disqualifying medications, and denials for failure to provide additional
medica! information, with annual rates per 1,000 active airline pilots of
2.3, 1.3, and Lil, respectively (see Figure 5}-

The highest causes for denial by specific patholory are: (i) use of
disqualitying, medications (65 percent of these were alse denied due to
‘cardiovascular pathology); (ii) myocardial infarction; (iii) alcoholism;
(iv) coronary artery disease; (v) bypertension with medication, and (vi)
coronary artery bypass surgery (see Figure 6). These six specific
causes account for almost 50 percent ef all causes for denial.

Of the 43 denials for use of disqualifying medication, 28 (or 65
percent) were also denied because of cardiovascular problems. Of the 27
denials for hypertension with medication, 16 (or 60 percent) were also
denied for disqualifying medication. Of_the 30 denied for coronary artery
disease, [2 "were also denied due to coronary artery bypass surge of

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Five-year age groupings, beginning with age 25 and ending with age
59, were utilized since they are closest to the age limits set by FAR's
61.151 and 121.383 (c) for tiolding an air transport pilot rating and
engaging in air carrier cperations,

Prevalence data regarding pathology represent conditions cited as
cause for denial -- not number of airline pilots. Some pilots denied. for
legal or administrative reasons would not necessarily have a pathology
code assigned and others are denied for two or more specific causes.

FINDINGS AND DISCUSSION

Observations on the airline pilot group probably come closest to a
true reflection of incidence of disquatifying disease as is possible to
observe. Prescreening by airline companies before employment and the
stringent FAA requirements for issuance of a first-class medical certifi-~
cate result in this group being essentially purged of disease prevalence
that contributes to higher rates for other groups. Also, because of
occupational/economic reasons, these individuals are less likely to volun-
tarily remove themselves from followup observation for known medical
conditions, that would preclude FAA medical certification. Conversely,
voluntary attrition is a more frequent occurrence among nonocecupationally
connected pilots who recognize that they are not medically qualified and,
therefore, are never heard from again by. the FAA.

Denials may occur at several different levels within the FAA and/or by
the AME. The final level of denial is, however, the one recerded on a
pilot's medical record. Of the 296 airline pilot denials, 32.1 percent
were general denials issued by the AMCB; 22.3 percent were ach
or legal denials by the ANCB; 17.6 percent were AME denials:
were exemptions previously issued, and then terminated/denie
were mandatory denials issued by the AMCB; 6.1 percent wers initial
exemption denials; 5.1 percent were Federal Air Surgeon de 1s; and 4.0
percent were denials under FAR 67.31 for failure to provide additional
information (see Figure 1).

istrative
percent
6.4 percent

As of December 31, 1978, there were 36,484 airmen between the ages ot
25-59 who listed their occupation as airline pilot. As of July lt, 1980,
there were 296 airline pilots who had been denied first-class medical
certifications during the past 2 years. A small number of pilots who
had been denied during the previous 2 years and had already reapplied and
had been issued certificates could not be considered in this study.

The annual denial rate for airline pilots is, therefore, 4.1 per 1,000
active airline pilots. This annual denial rate compares with an annual rate
of 4.3 for all first-class medical certificate holders; 4.9 for second~"
class; 8.9 for third-class; and 6.8 for all classes of medical certificates
(see Figure 2).

Fifty-two percent of the denied airline pilots had over !5,000 tots!
reported flying hours, with 70 percent reporting over 10,000 hours. This
reflects the fact that the majority of airline pilot denials are in the
older age intervals, i.e., those pilots with a considerable number of
total flying hours (see Figure 3).



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‘ CHARACTERISTICS OF MEDICALLY DISQUALIFIED
AIRLINE PILOTS

Technicol Report Documentation Page.

cerry

Shirley J. Dark

5

on Nowe ana A:
FAA Civil Aeromedical Institute
* P.O. Box 25082

Oklahoma City, Oklahoma 73125

Pertorming O° 397

120 Sponsenng Agency Nome and Aaaress
Office of Aviation Medicine
Federal Aviation Administration
800 Independence Avenue, S.W.
Washington, D.C. 20591

1S” Supplementans Notes

Ve. Abayracr
“Observations on the airline pilot group probably come as close to a true
veflection of incidence of disqualifying disease as is possible to observe.
Prescreening by airline companies before employment and the stringent Feceral
: iation Administration (FAA) requirements for issuance of a first-class medical
cate result’ in this group being essentially purged of disease prevalence that
contributes to higher rates for other groups. Also, because of occupational /economic
' reasons, these individuals are less likely to voluntarily remove themselves fron
followup observation for known medical conditions that would preclude FAA medica:
certification. Conversely, voluntary attrition is a more frequent occurrence amonz
fonoccupationally connected pilots who recognize that they are not medically
qualified and, therefore, are mever heard from again by the FAA.

Age-specific denial rates for airline pilots increase to the highest rate at
age interval 55-59. Tne most significant causes for denial are cardiovascular,
neuropsychiatric, and the miscellaneous category. The importance of these causes
| for denial, particularly above age 45, is again recognized. Aze-cause-szecific
findings for the airline pilot group follow epidemiologic. expectations, with age
being a significant variable associated with increased rates.

Of interest in the data on denial by employer is that the larger employers,
many of which have their own medical facilities, have uniformly lower deaial
‘ rates than smaller employers,
a.

V5. Key words \ 18. Cratmbunon Statement

j Airman Certification (Medical) " Document is available to the public

; Pilots, Denied ' through the National Technical
Statistical Analysis : Information Service, Springfield,

: Virginia 22161

f 19. Security Class, cof this report) 1 20, Securty Classe. of ara page! TTF Ne. St Sager =

‘ Unclassified H Unclassified 14

“Form DOT F 1700.7 #

Reproduction of completed page ovthor red
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Use of Disqualifying Medication ~
(65% for Cardiovascular Disease)

Myocardial Infarction
Alcohotism

Coronary Artery Disease
Hypertension with Medication

Coronary Artery Bypass Surgery

Failure to Provide Additional
Information (FAR 67.31)

Other Heart Pathology (Includes
Occlusion, Stroke, Aneurysm,
Thrombosis, Hemorrhage)

Disturbance ot Consciousness

Psychoneurotic Disorders
Fibrillation (Auricular)

Hypertensive Cardiovascular Cond.
Defective Distant Vision

Miscellaneous Ear Pathology
(Excluding Hearing Loss}

Annual Rate per 1,000 Active Airline Pilots

Figure 6. The most frequently gecurring causes for denlai.

12



FAA-AM-83-5

DTIC FILE COPY

CHARACTERISTICS OF MEDICALLY DISQUALIFIED
AIRLINE PILOTS

Shirley 3. Dark .
Civil Aeromedical Institute
Federal Aviation Administration
Oklahoma City, Oklahoma

g OF TRAAye
sg .,
Fa %
§ g
SG
Stares of ©
ELECTE
APR29 1983 J
B
JANUARY 1983

Document is available to the public through the
National Technical Information Service
Springfield, Virginia 22161

Prepared for
U.S. DEPARTMENT OF TRANSPORTATION
Federal Aviation Administration
Office of Aviation Medicine
Washington, D-C. 20591

83 04 29 027


NOTICE

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June 1982


las

TABLE 1. AIRLINE PELOT DENIALS BY EMPLOYER

Employer

Airlift International
Airvest

Alaska Airlines

Allegheny Airlines

american Airlines*

Braniff International Airways
Continental Airlines*

Delta Air Lines

Eastern Air Lines*

Flying Tiger Lines

Frontier Airlines

National Airlines

-Nerth Central Airlines
Northwest Airlines*

Ozark Air Lines

Pacific Southwest Airlines
Pan American World Airways*
Piedmont Aviation

Seaboard World Airlines
Texas International Airlines
Trans International Airlines
Trans World Airlines*

United Airlines*

Western Airlines

World Airways

Annual
Denial Rates
Per 1,000

Active Airline Pilots

Sow aLUbuHuiuoe

4
6
6
3
2
3
2
3
2
4
38
1
2
3

or

UboUwlH Ee Raone

me

Note: Asterisks indicate those airlines that have had their own
medical facilities or cooperative agreement with a medical

facility.


Cardiovascular

Neuropsychiatric

Miscellaneous
(includes
Endocr Inopathies, etc.)

Eye’

Ear, Nose, Throat

Abdominal
(Mostly GI, GU)

Bones and Joints
Respiratory

Muscles

Ses

1.27

1.07

0.25:

0.15

do.2

0.08

0.03

2.29

Annual Rate per 1,000 Active Airline Pilots.

Figure 5. Cause for denial of airline pilots by
Major body system.