XN

Much has nut been covered that pertains to the FAA medical certification
system. Much could be said about the man-machine aspects of our totat
aviation system, with the present. imbalance heavily weighted toward the

machines. Much cculd also be said about the. human maintenance concept as
applied to civil airmen.

Of fundaméntal concern is that éach AME strive to practice good, sound medi-,
cine consistent with the state of che act and as it relates to the special
environment of flying. All persons involved in aviation medicine have
responsibilities to the pilot and his or her reliability; to the air traffic
controller, who at times must be the eyes and ears of the pilot; to the pas-
sengers, who want to fly im safety; and to the general public, who ave con~
cerned not only with safety, but also the noise and the pollution problems of
the modern day airport.

U.S. Government Feimeing Office : 1987 - 3o-307/8761 ey

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United States. Government.

contents or use thereof.

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the Philosophy of Medical Certification and Standards

The FAA's medical certification philosophy is governed by the FAA's mission.
That mission, in a nutshell, ic to promote aviation while assuring safety in
the air and on the ground. Cleari:. that mission would not be well served if
people with performance~impairing meaical conditions are allowed. to perform

airman duties. Accordingly, FAR Part 61.53 provides:

No person may act as pilot-in-command, or in any other
capacity as a required pilot flight crewnember, while he
has a known medical deficiency, or increase of a known
medical deficiency, that would make him unable to mect the
requirements for his current medicai certificate.

What medical deficiencies are likely to cause an airman to fail to meet “the
requirements for his medical certificate?” Unpredictable, sudden, or
insidious incapacitation are the primary medical criteria applied by the FAA.
The FAA is interested in those organ systems most likely to be associated with
incapacitation--namely, the special senses, the cardiovascular system, the
nervous system, and the respiratory system. Obviously, then, the FAA places
special emphasis on disease or habits that affect these systems-~arterio*
sclerotic heart disease, hypertension, diabetes, epilepsy, mental disorders,
and indiscriminate use of drugs and alcoho}. Medication can affect these
systems too, vy producing incapacitating side effects. The FAA's aim is to
correlate pathology and its treatment with performance. By performance, the
FAA jeans not only motor skills, but judgment as well.

In deciding whether to issue a certificate under the special issuance
("waiver") provisions of the regulations, the FAA must balance the needs and
desires of the applicant against the riska to society. The FAA recognizes
that individuals should be allowed the maximum freedom, consistent with safety
in air commerce, in deciding the extent to which their exercise of airman
privileges should be limited by their personal health.

On the other hand, safety in air commerce demands that an individual with a
potentially incapacitating medical condition not be allowed to operate air~
craft under circumstances in which there would be a significant risk of injury
to other persons in the air or on the ground, or of substantial damage to the
property of others. The commercial or airline transport pilot, in virtually
every circumstance, has the life or property of another individual in his or
her care.. For this reason, if there is a significant risk that such a pilot
may experience an incapacitating medical event, he or she should not be per~
mitted to perform airman duties. When transportation by an air carrier is
involved, the Federal Aviation Act requires the Administrator, on whose behalf
the Federal Air Surgeon acts, “to consider the duty resting upon air carriers
to perform their services with the higheat possible degree of safety in the
public interest."

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REGULATORY AVIATION MEDICINE
1TS PHILOSOPHIES AND LIMITATIONS

The application of aviation medicine js relatively standardized throughout the
world, both in civil and military operations. Substantial differences exist,
however, in the way different countries, or even different agencies in the
game country, determine the medical qualifications of persons who wish to
operate aireraft. As 2 rule, the medical certification policies of the
Federal Aviation Administration (FAA) are more liberal than those imposed by
the U.S. Department of Defense and by many foreign countries.

Understanding the reasons for these differences requires on awareness of the
characteristics of FAA's regulatory policy. Specifically, we must consider
three aspects of that polic (1) the certification system and its overall
effects, (2) the philospophy of medical certification and - standards, and
(3) the limitations of the system.

The Medical Certification System and its Overall Fifects

For purposes of civil medical. certification, the term “airman” includes
pilots, certain other flight crew members, and air traffic contro] tower
operators who are not employed by the FAA. The FAA issues pilot certificates
based on demonstrated skill, knowledge, and experience. Pilots may use their
certificates to perform airman duties if . they obtain periodically required
medical examinations and receive the appropriate medical certificate.

There: are three classes of medical certificates:

1. First-class certificates are necessary for performing duties that require
an airline transport pilot certificate. To maintain first-class certifi~
cation, examinations are required at 6-month intervals.

2. Second-class certificates are necessary for performing duties that require
a commercial pilot certificate. To maintain second-class certification,
examinations are required at }2-month intervals.

Third-class certificates are necessary for performing duties that require
a student pilot or private pilot certificate. To maintsin third-class
certification, examinations are required at 24-month intervals.

In 1927, the first’ full year of Federal certification of airmen, 4,200 medical
certificates were issued in the United States; in 1980 530,000 were issued, or
an average of about 1,450 for each day of the calendar year. Over 100,000 new
airmen come into the system each year.

Designated Aviation Medica! Examiners (AME) perform all medical certification
examinations. AME's. are physicians in private practice. The FAA selects
these practioners on the basis of their interest in aviation medicine,
experience and expertise, and the need for examiners in a given. locality.


Technicol Report Documentation Page

TS. Reerprent + Coreieg No

T. Report No

FAA-AMr 82-14

[3 Revert Oe

\__ September 1982

T Titte and Sobre

Regulatory Aviation Medicine Belong &

ronan Goee

J

r
Its Philosophies and Limitations LL

Perlormng Orgonizarian Renan Ne

7 Avthors

Jon L. Jordan, M.D. ___ Gordon Norwood, M.D

Fo Peitorming Orgotsrarion Name ond Addrens 10. Work Unw No (TRANS!

Federal Aviation Administration

Office of Aviation Medicine Tl Contract or Grant No.
800 Independence Avenue, sw. ;
Washington, D.C. 20591 _. 13. Type of Reppre and Period Covered

TZ. Sponsoring Agency Nome and Address

Ta. Sponsanng Agency Code

15, Supplementary Notes

Té
Vine application of aviation medicine is relatively standardized throughout the
world, both in civil and military. operations. Substantial differences exist,
however, in the way different countries, oF even different agencies in the
same country, determine the medical quatificatiors of persons who wish to
operate aircraft. As a rule, the medical certification policies of the
Federal Aviation Administration (FAA) are more Liberal than those imposed by
the U.S. Department of Defense and by many foreign countries.

barree?

Understanding the reasons for these differences requires an awareness of the
characteristics of FAA's regulatory policy. Specifically, we must consider
three aspects of that policy: (1) the certification system and its overall
effects, (2) the philosophy of medical certification and standards, and

(3) the Limitations of the ar

iT. Kay Words TE Ovinibetion Stovement

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

T9. Secunty Clavsih (ol this report Hi. Seevinty Clensit, (of thrs poge) i Ne. ol Pages | 22. Price

Unclassified Unclassified 8

Form DOT F 1700.7 (8-72) Reproduction of completed peg euthorized

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Since AME failure means system failure, the computer is also used to survey
the work of all AME's. This assures that each AME is performing careful
examinations and issuing medical certificates in keeping with agency
standards, policies, and procedure s+

under tne, medical standards, 10 conditions are disqualifying on the basis of
history alone. They are’ a0 established medical history or clinical diagnosis
of (1) myocardial infarction, (2) angina pectoris, (2)Y coronary heart disease
that has required treatment or, if untreated, has been symptomatic or clini-
cally significant, (4) peychosis, (5) 3 personality disorder manifested by
overt acts, (6) epilepsy, (J) a disturbance of consciousness without satis
factory medical explanation of the cause, (8) drug dependences (9) diabetes
mellitus that requires hypoglycemic medication for contro}, and (10) alcon
holism, unless there is established clinical evidences satisfactory to the
Federal Air Surgeon, of recovery, iacluding sustained total abstinence from
alcohol for not less than the preceding 2. years.

An airman with 2 history or clinical diagnosis of any of these disorders, a5
well as any other disqualifying medical condition may, however, be considered
for certification by FAA medica) personnel under the special issuance
("waiver") prov: -as of Section 67.19 of the Federal Aviation Regulations
(rar). This type of reconsideration often requires special medical. or
practical tests. The applicant may be required to submit special followup
medical reports. After careful evaluation, most applicants are allowed to
fly, but the operational use of the certificates may be limited. For example,
an applicant who has problem distinguishing colors may be prohibited from
engaging in night flying or flight requiring color signal control. The use of
limitations allows the certification of airmen who would not otherwise de
. certificated; at the same time, the tevel of risk to safety is controlled.
Less than 1 percent of applicants are denied ail airman privileges. New
airmen receive .@ disproportionare share of denials. They comprise only
20 percent of all applicants, yet they receive approximately 50 percent of all
denials. :

In any 1 year, about 1,000 airmen will appeal their denials to the Federal Air
Surgeon. Of those persons who appeal to the Federal Air Surgeon, approxi-
mately 400 will be certificated. It might be asked whether aviation safety is
endangered by so few denials. Special followup medical evaluations, however,
control the risk assumed. veoee
Airmen who receive a final denial from the FAA can appeal to the National
Transportation Safety Board (NTSB) for a “rules of evidence" hearing to deter~
mine if the regulations were appropriately applied. The airman may appear at
the hearing on his or her ow behalf or may be represented by legal counsel.
the FAA is always represented by legal counsel. Testimony is presented to an
Administrative Law Judge, who issues an initial decision.. Fither party may
appeal that decision to the full Board. Legal briefs are prepared for the

appeal, but no further testimony is required.

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Cameron Station + Alexandria, Virginia 22314

UNCLASSIFIED


At the time, goggles could not be ground to prescription, and vision had to be
normal without cerreetion. The standards were fairly. rigid, and a pilot, whea
grounded, Had no established avenues of appeal. Since the first civil stan~
dards, established in 1976 by the lepartment of Commerce, grew ovt of the
military's experience, they, foo, were empirical in origin; morecver, they
bore the same rigid characteristics as the military standards. And -they
retained these characteristics for many vears. :

With the advent of the FAA a new philosophy toward aeromedical standards
emerged, Years of accunulated experience had made it apparent that with some
cwmpensation for deficiencies--e-a-, using asses or taxing special
training--pilets could perters. fely. Hence, certain standords were relaxed,
“waivers” were ssved, and an appeal tem tas established.

Today's standards are not highly detailed. Qn the cther hand, during aay
given physical examination, there are almost no limits te historical detail or
to the number of tests that might be employed. The procedures chosen wil!
depend on the examining physician's clinical judgment. At the same time, the
FAA's medical regulations must bevvand arencdirected toward those relatively
feu areas where discovery of disease or risk to safety is likely.

It goes without saying that AME's wust apply the FAA's, standards to documented
medical evidence. But in the daily practice of medicine, practical limita~
tions and compromises in auta accunulation and interpretation TYead to some
professional differences of opinion. There is .a fundamental difference,
moreover, between the private practice of medicine, where physician-patient
relationships are paramount, and the practice of regulatory medicine, where
the public interest must be the foremost consideration. It .is often because
this fundamental difference is not appreciated by airmen or physicians that
misunderstanding arise hetween equally dedicared and competent physicians.
Basic to both types of practices is the fact that we mest depend upon what the
individual reveals by history and what is found on examination.

Many pilots share a basic mistrust of flight surgeons and AME's, They are
required te undergo a physical examination at repular intervals and te pay for
something, they often do not want or think is necessary. AME's are a potential
threat to their career ss pilots or to the pleasure and ‘the investment they
have in flying. But the AME is also an influence on the formation or suppres-
sion of these attitudes. Knowing they exist, an AME can be more alert to the
evasiveness of some applicants. A carefully documented history and examina~
tien is fundamental te the reliability of the certification system and in
assuring safety. Without reliable medical information obtained from a
conscientious airman by a thorough physician, the medical standards are
impotent. The certification decision made must be consistent with the evi-
dence in the written record of the individua]. Unfortunately, not only are
there pilots who have and conceal serious medical conditions, but there are
also physicians who know and withhold the information by omission, and occa
sionally, by comnission.


Limitations of the System

With this philosophy as backgrcund, we can now examine how the FAA goes about
developing and implementing safety rules, regulacions, and standards.

The Federal Aviation Act directs the FAA to promote safe flight by prescribing
minimum standards governing the issuance of airman certificates and the
design, materials, workmanship, construction, and performance of aircraft.
The Act does not define these standards; it merely authorizes the establish-
ment of standards, which the FAA does in the FAR. .

FAR Part 11 sets aut the procedures the FAA must follow in making rules.
These procedures assure that tHe public and those people subject to new or
amended rules have an opportunity to be heard and, hence, participate in the
rulemaking process. This is not to say thar the FAA passes the responsibility
for rulemaking to others or. that regulations are adopted by popular vote. The
final rulemaking determination still rests with those individuals who have a
statutory responsibility for representing the public interest.

All rules must stand the test of review by the courts. cc means they must
be within the statutory power of the agency, must not infringe upon constitu-
tional rights, must not be arbjtrary or capricious, and must. not abuse dis-
cretionary authority. The role of the FAA's Office of Aviation Medicine in
air safety is predominately regulatory. In prescribing reasonable minimum

medical standards, the Office practices regulatory medicine.

The teed for standards is clear. The uncontrolled diabetic or epileptic
should not be permitted to operate an aircraft. On the other hand, the
general application of medical standards must be flexible. Exceptions to the
rules: are granted when it is clear’ that the risk to aviation safety is not
significant. Difficult cases require individualized consideration. The only
stipulation is that the final décision mist be made by persons who sre in the
full-time practice of aviation medicine and who have the ultimate responsi~
bility for ensuring safety. :

It may seem irresponsible to some people to talk of costs in the same breath
with safety. Yet in the real world such considerations must be made. People
accept calculated risks as part of their general attitude toward life, because
they know that absolute sefety, if it could be attained, would have economi-
cally intolerable consequences. Therefore, the FAA's goal is not absolute
safety; it is, rather, to maintain the highest level of safety that can be
achieved with the expenditure of a reasonable amount of resources,

Tae earliest aeromedical standards were more rigid than ‘today's. During World
Wer I, many people who had been rejected by the infantry became pilots. The
U.S. Army soon realized that airmen with physical defects had a much higher
accident rate than airmen without defects. This realization led to the first
medical standards. for pilots and to the development of aviation medicine as: a
specialty, But with no one having prior. .ggperience in the aeromedical field,
the first standards by and large were arbitrary. or geared to the equipment and
the type of flying--namely, goggles and open-cockpit aircraft.



The airman pays the physician's fees. The FAA does not, reguiate these fees;
it does, however, ask AME's to charge fees that are commensurate with current

rates in their communities for similar examinations.

There are over 8,000 AME's in the United States, including 500 military, and
300 international. Almost 45 percent are pilots and some 18 percent are
former military flight surgeons.

The AME's role is unique. The AME is the only FAA designee or representative
with whom every pilot has a regular and required contact. We or she is,
therefore, ideally situated to participate in grass roots aviation and to
contribute co the ongoing education of airmen. Moreover, in practicing
preventive medicine, the AME can be instrumental in preserving the careers,
health, and well being of America's airmen. This may be achieved through the
eatly detection of conditions which, unless vigorously treated, will become
disqualifying.

The FAA designates only a limited number of physicians as AME's. There are
good reasons for limiting the number of AME's, even though it means that some
family physicians are excluded from the medical certification process, Many
physicians have no special interest in aviation medicine and are not inclined
to become involved in the administrative details of certification. Others
simply do not have the time to perform the type of examination requited by the
FAA and are unwilling to obtain the necessary training to become an effective
link in the medical certification process. i

The AME not only conducts medical examinations of airmen applicants, but also
is authorized to issue or deny medical certificates. These certificates are
required by everyone performing airman duties.

An airman should be aware that in the event of an aircraft accident or opera~
tional incident, Federal authorities will automatically check to determine
whether he or she holds a@ current medical certificate and whether the certifi-
cate is appropriate for the airman duties that were being performed. In addi-
tion, it is likely that the validity of insurance will be contingent upon
proper certification.’ : .

AME's submit airman medical reports to the FAA's Aeromedical Certification
Branch in Oklahoma City, where they are reviewed for completeness and for con~
formity with agency policy and procedures. Information from the reports is
fed into a computer for screening. If a report fails the computer screening,
it is reviewed manually.

problems that go beyond simple clerical error are referred to an FAA physi-~
cian. The physician may ask the airman for additional information, such as
hospital records or a specialty examination. Aeromedical flight testing to
determine an individual's competency may also be required. After all the
information is received, eligibility for medical certification is decided and
the computer record is updated, creating a4 data. bank. for special studies. .



NN

REGULATORY AVIATION HEDICINE
ITS PHILOSOPHIES AND LIMITATIONS

Gordon Norwood, M.D.
Jon.L. Jordan, M.D._

"office of Aviation Medicine ee
“¥ederal Aviation Administration’
: Washington, D.C.

stars

-_ Septenber 1982

Prepared. for
"DEPARTMENT OF: ‘TRANSPORTATION x
“Federal Aviation. Administration
Office of Aviation, Medicine



ig
arr

JACK R. HUNT MEMORIAL LIBRARY
DAYTONA BEACH, FLORIDA 904-226-6595

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Therefore, if you know of the existence of any significant reports, etc.,
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June 1982


Flight instructors commonly intercede on behalf of applicants, confuring skidl
and knowledge with health factors. Physicians occasionally express strong
opinions abcut the eligibility of an airman with a pethologic cendition that
they would normally consider outside the range of their expertise. They argue
that, as exomining phyticisns, they are in the best position to know. They
criticize the FAA for making armchair" decisions.

The FAA recognizes that these criticisms have sone validity, but contends that
there are other factors to consider:

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

2. The agency often obtains specialty reports not available to the AME.

3. The specialist in aviation medicine may know of factors that the busy
practitioner may not have considered.

Ie is necessary, therefore, for the examining physician to keep the channels
of communication open and to confer with agency persennel when appropriate.
If the, AME is in doubt about what to do, he or she is instructed not to issue
a medical certificate.

In locking at the pitfells ard limitations of rules, it is understandable that
education is preferred to regulation. The FAA has neither the inclination nor
the resources to keep America's civilian pilots uncer constant surveillance.
Much will.depend upon the knowledge and honesty of the individual pilot. The
pilot must be advised of the physiological consequences of illness, fatigue,
érugs, and alcohol. Written FAA pilot examinations contain questions related
to such knowledge and many safety meetings include lectures in aviation
physiology.

There is a continuing need for AME education. Short 3-day seminare are hela
each year throughout the United States. Longer, more advanced seminars are
held at the Civi) Aeromedical Institute in Oklahoma City. AME's are also
provided with further assistance through the Guide for Aviation Medical
Examiners. The Guide anc the seminars are cesigned to assist in using 2 set
of regulations that allow latitude in interpretation.

Summary

The medical certification system has been sketched to explain the role of the
AME and the processing of applications by the FAA, The overall effects of the
system have been portrayed to reflect the rather liberal modes of appeal
available to the airman. To better understand these effects, the philosophy
of certification and standards was reviewed. While incapacitation is of
primary concern to safety, promotion of aviation leads to other considera~
tions, including individual rights, levels of concern, and differing responsi~
bilities. In considering system limitations, the manner in which new regula-
tions are developed, the empirical origins of the regulations, their brevity,
the need for documentation, and education were touched upon.