Toxicological Findings in 889 

Fatally Injured Obese Pilots 

Involved in Aviation Accidents

DOT/FAA/AM-10/10

Office of Aerospace Medicine

Washington, DC 20591

OK-10-0077-JAH

Sabra R. Botch

Marc S. Davidson

Eduard M. Ricaurte

Arvind K. Chaturvedi

Civil Aerospace Medical Institute

Federal Aviation Administration

Oklahoma City, OK 73125

May 2010

Final Report

Federal Aviation

Administration
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assumes no liability for the contents thereof.

___________

This publication and all Office of Aerospace Medicine 

technical reports are available in full-text from the Civil 

Aerospace Medical Institute’s publications Web site: 

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i 

Technical Report Documentation Page 

1. Report No. 2. Government Accession No. 3. Recipient's Catalog No. 

DOT/FAA/AM-10/10 

4. Title and Subtitle 5. Report Date 

Toxicological Findings in 889 Fatally Injured Obese Pilots Involved in May 2010 

Aviation Accidents 6. Performing Organization Code 

 

7. Author(s) 8. Performing Organization Report No. 

Botch SR, Davidson MS, Ricaurte EM, Chaturvedi AK 

9. Performing Organization Name and Address 10. Work Unit No. (TRAIS) 

FAA Civil Aerospace Medical Institute 

P.O. Box 25082 11. Contract or Grant No. 

Oklahoma City, OK 73125 

12. Sponsoring Agency name and Address 13. Type of Report and Period Covered 

Office of Aerospace Medicine 

Federal Aviation Administration 

800 Independence Ave., S.W. 

Washington, DC 20591 14. Sponsoring Agency Code 

15. Supplemental Notes 

Work was accomplished under approved task AM-B-10-TOX-202. 

16. Abstract 

Obesity continues to be a public health concern and its impact on aviation community has not been fully 

evaluated. Toxicological findings in fatally injured aviation accident obese pilots were examined. The Civil 

Aerospace Medical Institute's (CAMI's) Scientific Information System was used to develop a dataset, entailing 

fatally injured obese pilots involved in aviation accidents, 1990–2005. A pilot with a body mass index (BMI) 

of > 30 kg·m•2 was considered obese. Toxicological results and aeromedical histories of these aviators were 

retrieved from the CAMI toxicology and medical certification databases, and the cause/factors in the related 

accidents were retrieved from the National Transportation Safety Board's aviation accident database. In 311 of 

the 889 pilots, carbon monoxide, cyanide, ethanol, and drugs were found, and glucose and hemoglobin A1c 

(HbA1c) were elevated. Many of these drugs were for treating overweight, depression, hypertension, and cardiac 

conditions. In a pilot (BMI: 39.33 kg·m•2) wherein phentermine was detected, vitreous and urinary glucose 

concentrations were 301 and 6,050 mg 11.5 dL•1, respectively; HbA1c was 12.4%. Of the 889 pilots, 107 had an 

obesity-related medical history. The health and/or medical condition(s) of, and/or the use of ethanol and/or 

drugs by, pilots were the cause/factors in 55 (18%) of the 311 accidents. Although the drugs found are 

commonly used in the general population, they were primarily used for treating obesity-related medical 

conditions. Findings emphasize monitoring of obesity and diabetes in pilots and understanding the potential 

implications of these health conditions in relation to flight safety. 

 

17. Key Words 18. Distribution Statement 

 

 

Forensic Science, Toxicology, Obesity, Pilot Fatalities, 

Drugs, Ethanol, Glucose, Hemoglbin A1c, 

Civil Aviation Accident Investigation

Document is available to the public through the 

Defense Technical Information Center, Ft. Belvoir, VA 

22060; and the National Technical Information 

Service, Springfield, VA 22161 

19. Security Classif. (of this report) 20. Security Classif. (of this page) 21. No. of Pages 22. Price 

Unclassified Unclassified 15 

Form DOT F 1700.7 (8-72) Reproduction of completed page authorized 

iii 

Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Materials and Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

 Scientific Information System (SIS) Database . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

 Toxicology Database . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Medical Certification Database . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

 Aviation Accident Database . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Biological Specimens and Toxicological Analyses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

 SIS Dataset . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Medical Certification and History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

 Toxicological Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

 Reported Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

 Cause or Contributing Factor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

1 

Toxicological Findings in 889 Fatally Injured

Obese Pilots Involved in Aviation Accidents

Introduction

Obesity in the United States general population has 

been on the rise over the past 25 years and continues to 

be a public health concern (20). In 2007, the prevalence 

rates for diabetes and obesity in the United States were 

> 10.6% and > 30.9%, respectively (9); the dominance 

for diabetes in U.S. counties ranged from 3.7% to 15.3% 

(median: 8.4%) and for obesity from 12.4% to 43.7% 

(median: 28.4%). Individuals with a body mass index 

(BMI) > 30 kg∙m−2 are considered obese (9, 26), and BMI 

is a generally accepted practical approach for assessing fat 

(21). However, this index has limitations—for example, 

overestimation of body fat in very muscular persons and 

underestimation in elderly (4). In spite of these limitations, BMI is an accepted method for measuring body 

fat based on height and weight, regardless of age, gender, 

race, or ethnicity (18, 19, 26). Individuals with obesity 

have patho-physiological potentials to develop a number 

of medical conditions that could be associated with the 

adverse effects of excess visceral abdominal fat (4, 5, 

34). Abdominal obesity has been linked with coronary 

heart disease (22). The comorbidities of obesity include 

diabetes, high cholesterol, hypertension, cardiovascular 

disease, depression, obstructive sleep apnea, stroke, arthritis, certain cancers, and risk of disabilities and all-cause 

mortality (2, 4, 5, 27, 34).

Because of the growing concern with the medical issues related to obesity, it is important to understand and 

address this issue in the aviation community, particularly 

with respect to the airman seeking or maintaining the 

required medical certificate to fly an aircraft. In a 10-year 

study, it has been found that commercial pilots who were 

obese had a 22% higher risk of cardiovascular disease than 

their counterparts with normal BMI values (29). In the 

2008 Aerospace Medical Association panel on diabetes, 

it was reported that the median BMI in the U.S. civilian 

pilot population was increasing (30, 35). Therefore, it is 

important that the aviation medical community monitor obesity and its potential implications with respect to 

flight safety.

The Federal Aviation Administration’s (FAA’s) Civil 

Aerospace Medical Institute (CAMI; Oklahoma City, 

OK) has been determining concentrations of glucose in 

vitreous fluid and urine and of hemoglobin A1c (HbA1c) 

in blood samples collected from pilots who were fatally 

injured in civil aviation accidents. This determination is 

carried out to establish if the disease of diabetic pilots was 

controlled at the time of the accident and/or to identify 

pilots with undiagnosed or unreported diabetes (7, 11, 

37). Findings of these studies concluded that all of the 

aviators were not aware of, or did not report, elevated 

glucose levels or the diabetic condition. Concentrations 

of glucose and HbA1c from fatally injured aircraft accident 

victims have been helpful in establishing whether the 

hyperglycemia-related performance impairment was the 

probable cause or a contributory factor in the accidents.

Aeromedical aspects of obesity and diabetes have been 

elaborated in the literature (30, 35, 36), but toxicological findings in obese pilots have not been examined.The 

present study was conducted to evaluate and discuss 

such findings in the fatally injured obese aviators. Also, 

examined in the study were the pre-existing medical 

conditions mentioned in the medical certifications of 

those pilots and the probable cause/contributing factors 

in those aviation accidents, as concluded by the National 

Transportation Safety Board (NTSB) (25).

Materials and Methods

Scientific Information System (SIS) Database

The SIS aviation safety database of the U.S. pilot 

population from 1983 through 2005 was developed at 

CAMI (28, 30, 31). For the present study, this database 

was used to obtain a population dataset of pilots spanning the period of 16 years (1990–2005). Obtained by 

performing a longitudinal analysis of the entire airman 

population residing in the SIS database, the dataset utilized 

in the present study was associated with those aviators 

who were obese and involved in civil aviation accidents.

This dataset consisted of fatally, as well as non-fatally, 

injured aviators.

Toxicology Database

Since 1990, a toxicology database for civil aircraft accident fatalities has been maintained at CAMI (15). In 

this database, toxicological results, including applicable 

glucose and HbA1c concentrations and DNA profiling, are 

electronically stored (14, 15). Also, incorporated in the 

database are other relevant data concerning the accidents 

and the victims (10, 15). Such information is obtained 

from the FAA Administrator’s Daily Alert Bulletin, the 

NTSB Web site, the FAA airman and medical certification records, and other sources. The CAMI toxicology 
2 

database was searched for the 16-year period (1990–2005) 

for the fatally injured pilots of the obese pilot population 

dataset (see the previous subsection, Scientific Information 

System [SIS] database) from whom postmortem samples 

were submitted to CAMI.

Medical Certification Database

The CAMI medical certification database (Document 

Information Workflow System) was used to retrieve 

necessary information from the most recent medical 

examination pertaining to a particular aviator who was 

fatally injured in an aviation accident that occurred during 

1990–2005. The information consisted of examination 

date, height, weight, medications used, medical conditions 

and associated pathology codes, and medical certificate 

type. Obesity (BMI > 30 kg∙m−2) was re-calculated by 

height (m) and weight (kg) recorded in the medical 

examination of the aviator prior to the fatal accident 

to confirm that the BMI value was consistent with the 

criterion for determining obesity. The pathology codes 

documented on the medical examination records were 

used to identify airmen with medical conditions associated with obesity. Information on the medical certificate 

types (first-, second-, or third-class) of aviators (17) was 

also retrieved from the database.

Aviation Accident Database 

The NTSB’s aviation accident database was used to 

obtain accident-related information such as flight categories, probable cause, and contributing factors in the 

accidents (25).

Biological Specimens and Toxicological Analyses

Biological samples collected from pilot fatalities associated with U.S. civil aviation accidents are submitted 

to CAMI in the FAATOX-BOX evidence containers for 

toxicological analyses (3, 14, 15).The sample submission 

is requested by the NTSB, in coordination with the FAA

Office of Accident Investigation (Washington, DC), for 

the investigation of aircraft accidents occurring within 

the jurisdiction of the United States.The types of samples 

generally received at CAMI are blood, urine, vitreous fluid, 

spinal fluid, brain, lung, heart, liver, kidney, muscle, and 

other biological samples.

Following the standard operating procedures of 

CAMI’s laboratory, the submitted samples are analyzed 

for the presence of combustion gases, ethanol/volatiles, 

and drugs. The presence of these analytes is analytically 

demonstrated by screening, followed by confirmation and/

or quantitation. The combustion gases include carbon 

monoxide as carboxyhemoglobin (COHb) and hydrogen 

cyanide as cyanide ion (CN ̄); the drugs entail a wide 

range of prescription, nonprescription, and illegal drugs 

(13, 15). Vitreous fluid and urine samples are analyzed for 

glucose; blood for hemoglobin A1c (HbA1c) (7, 11). Glucose and HbA1c analyses were formally implemented on a 

routine basis in the CAMI laboratory in 1998 and 2001, 

respectively. Concentrations of glucose > 125 mg∙dl−1 in 

vitreous fluid and > 100 mg∙dl−1 in urine are considered 

elevated (7, 11). Postmortem blood HbA1c values > 6.0% 

correlate well with a known history of diabetes and with 

the elevated vitreous fluid and/or urine glucose levels 

in the fatally injured pilots and, thus, the HbA1c values 

> 6.0% are considered elevated (7, 11, 12, 37). DNA

profiling is performed on case samples in which there 

is a doubt about the identity of the submitted samples 

(14). These toxicological evaluations are summarized in 

a 2009 review (10).

Results

SIS Dataset

The obtained SIS dataset was associated with those 

aviators whose BMI values were > 30 kg∙m−2 and who 

were involved in fatal or non-fatal U.S. civil aviation 

accidents that occurred from 1990 through 2005. The 

number of pilots who met these parameters was 3,876.

Of this population, 967 pilots were fatally injured; this 

number was re-confirmed by the NTSB database. Of 

the 967 fatalities, postmortem samples from 897 (93%) 

were submitted to CAMI. With eight aviators, there were 

discrepancies in the SIS and toxicology databases with 

respect to the data elements (such as age and gender) and 

the misclassification of a pilot as to be a passenger, and/or 

the submitted samples of the pilot were not toxicologically 

analyzed.Therefore, these eight pilots were excluded from 

the 897 dataset, and the retrieval of medical, toxicological, 

and accident investigation information from the databases 

was limited to 889 pilots (Fig. 1).

Based upon the height and weight values recorded at 

the time of the most recent aviation medical examination, the BMI values of all of the 889 aviators were reconfirmed that the values were equal to or greater than 

30 kg∙m−2 prior to the accidents (Table I). The majority 

of the aviators in the toxicology dataset were male—that 

is, 876 (98.5%) males and 13 (1.5%) females.

Medical Certification and History 

Of 889 aviators, 108 held first-class, 344 second-class, 

and 437 third-class medical certificates (17). With respect 

to flying ratings, 436 pilots held private, 295 commercial, 

123 airline transport, and 33 student certificates (17).

Two pilots were not certificated.

One hundred seven (12%) of the 889 aviators had a 

medical history that could be related to obesity. Based on 

pathological codes that are used to register an aviator’s 
3 

Table I. Mean BMI (kg·m−2

), Height (m), and Weight (kg) Values of Fatally Injured Obese Male and 

Female Pilots Involved in Aviation Accidents 

Pilots BMI 

(SDn

*

; Range) 

Height 

(SDn; Range) 

Weight 

(SDn; Range) 

Males 

(n = 876) 

33.14 

(3.14; 30.02–61.62) 

1.78 

(0.08; 1.30–2.01) 

105.45 

(12.32; 71.67–175.54) 

Females 

(n = 13) 

34.16 

(3.93; 30.10–43.57) 

1.69 

(0.04; 1.60–1.75) 

97.87 

(13.84; 77.11–127.01) 

*

Standard deviation (SDn) based on the entire population given as argument—that is, data taken from every member of the population.

3,876 

Pilots 

(Fatally/Non-Fatally 

Injured; BMI ≥ 30) 

SIS Database 

967 

Pilots 

(Fatally Injured; 

BMI ≥ 30) 

897 

Pilot Fatalities 

(Postmortem 

Samples Received) 

Toxicology Database 

8 

Pilot Fatalities 

Excluded (Database 

Discrepancy and/or 

No Toxicology)

889 

Pilot Fatalities (Cases) 

(BMI ≥ 30 Prior to 

Accident) 

Toxicology Performed 

578 

Cases (Pilots) 

Negative 

311 

Cases (Pilots) 

Positive 

Figure 1. A flowchart representation of 889 

fatally injured obese civil aviation accident 

pilots whose postmortem biological samples 

were toxicologically evaluated.
4 

medical history, these 107 aviators reported or were diagnosed with the medical conditions shown in Table II.

More than one medical condition was reported in the 

records of some of the 107 pilots. The medical conditions—for example, diabetes, depression, hypertension, 

and cardiovascular conditions—reported in the records 

were conditions primarily associated with obesity. No 

obesity-related medical conditions were mentioned in 

the medical certification records of the remaining pilots.

Toxicological Findings

Of the 889 fatalities (cases), 578 were determined to 

be negative; the remaining 311 were positive cases (Fig.

1). In these positive cases, foreign substances—carbon 

monoxide, hydrogen cyanide, ethanol, and drugs—were 

found and/or endogenous substances—glucose and 

HbA1c—were elevated. In some cases, the presence of 

more than one foreign substance and the elevation of more 

than one endogenous substance (glucose and HbA1c) were 

observed.Therefore, those cases were counted more than 

once. Of the 311 fatalities, 11 were positive for COHb 

and/or CN ̄ and 302 for ethanol and/or drugs (Fig. 2).

In additional 11 fatalities, glucose and/or HbA1c were 

elevated; ethanol and/or drugs were also found in seven of 

these 11 fatalities. Along with concentrations of COHb, 

CN ̄, glucose, and HbA1c, the list of drugs found in the 

fatalities are tabulated in Tables III–V. Associated with 

COHb, CN ̄, glucose, and HbA1c cases, the cause/factors 

in aviation accidents and medical histories of pilots are 

also mentioned in Tables III and V.

As exhibited in Figure 3, ethanol was present in 36 

aviators. The Drug Enforcement Administration’s (16) 

controlled substances of Schedules I and II were found 

in 38 pilots and of Schedules III, IV, and V in two. The 

controlled substances include drugs such as amphetamine/

methamphetamine, cocaine, Δ9

-tetrahydrocannabinol 

(THC), and benzodiazepines (16). Prescription drugs 

were present in 203 pilots and non-prescription (overthe-counter) drugs in 303. Considering that more than 

one substance was present in some of these fatalities, the 

total number of instances for the presence of substances 

(ethanol/drugs) was 582.These substances (drugs) ranged 

from the commonly used prescription drugs—such as 

narcotic analgesics, benzodiazepines, and cardiovascular medications—to non-prescription drugs—such as 

antihistaminics, decongestants, non-narcotic analgesics, 

and quinine (Table IV). Including ethanol, some of these 

substances can cause performance impairment. 2 

Table II. Medical Conditions Mentioned in Medical Certification Examination Records of Fatally Injured 

Obese Pilots Involved in Aviation Accidents 

Medical Conditions Pilots 

Hypertension controlled by medication 51 

Calculus-bladder/renal/ureteral 19 

Diabetes controlled by diet and/or disturbance of carbohydrate metabolism 11 

Labile hypertension 10 

Diabetes controlled by hypoglycemic drugs 6 

Glycosuria or sugar in the urine 5 

Coronary artery disease/heart disease 5 

Coronary artery bypass surgery 3 

Unspecified cardiac disorder 3 

Hardening arteries, arteriosclerosis other than coronary 2 

Coronary angioplasty 2 

Myocardial infarction 1 

Angiography with 50% or less occlusion 1 

Other genitourinary condition 2 

Renal disease 1 

*

More than one medical condition was reported in some records.
5 

Cases Positive for 

Foreign, and/or With 

Elevated 

Endogenous, 

Substances 

311 

With Elevated 

Glucose and/or 

HbA1c

11 

 Glucose and/or 

HbA1c: 4 

 Glucose and/or 

HbA1c with Ethanol 

and/or Drugs: 7 

With 

COHb and/or 

CN ̄ 

11 

 COHb and/or CN ̄ : 

9 

 COHb and/or CN ̄ 

with Ethanol and/or 

Drugs: 2 

With 

Ethanol and/or 

Drugs 

302 

Figure 2. The number of pilot fatalities (cases) in which COHb, CN ̄, ethanol, and drugs 

were found, and glucose and HbA1c were elevated.
6 

Table III. Blood COHb and CN ̄ Concentrations in 11 Fatally Injured Obese Pilots Involved in Aviation 

Accidents

Number COHb 

(%) 

CN ̄

(μg·ml−1

) 

Fire Status Drugs Found in 

Biological Samples*

Pilot's Health and/or Medical 

Conditions as the 

Cause/Factors in the 

Accidents as Determined by 

the NTSB 

1 12 0.48 Ground fire —† — 

2 12 0.71 Ground fire — — 

3 — 0.50 Ground fire — Incapacitation of the pilot in 

command 

4 23 0.34 Ground fire — — 

5 16 — — — Physical impairment of the 

pilot‡

6 22 2.22 Ground fire — — 

7 13 — Ground fire — — 

8 33 0.93 Ground fire Lorazepam — 

9 13 — Ground fire — — 

10§ 45 — — 

Atenolol 

Diphenhydramine 

Pseudoephedrine 

Triamterene 

Failure of the left muffler, 

resulting in a carbon 

monoxide leak into the cabin 

rendering the pilot 

incapacitated 

11§

 53 — Ground fire — — 

*

Where possible, based upon multi-analyses in at least two different sample types. 

†

No analysis, negative findings, no drugs found, or no cause/factor. 

‡

Pilot was a mechanic and had been exposed to running engines in a non-ventilated shop the day/evening prior to the accident. 

§

Hypertension controlled by medication. 

Cases With 

Ethanol and/or 

Drugs 

302

With 

Ethanol 

36 

With 

Schedule 

I and II 

Drugs 

38 

With 

Schedule 

III, IV, and V 

Drugs 

2

With 

Prescription 

Drugs 

203 

With 

NonPrescription 

Drugs 

303 

Total 

Instances 

582 

Figure 3. Ethanol and drugs found in the fatally injured obese pilots involved in aviation 

accidents.
7 4 

Table IV. Drugs and Metabolites Found in the Fatally Injured Obese Pilots Involved in Aviation Accidents 

Drugs*

 and Metabolites 

Controlled Substances

Amphetamine Methamphetamine Cocaine Δ9-Tetrahydrocannabinol (THC)/THC 

Carboxylic Acid 

Prescription Drugs

Alprazolam Amitriptyline Amlodipine Atenolol Atropine 

Azacyclonol Bisoprolol Bupropion Butalbital Carbamazepine 

Cimetidine Citalopram Codeine Cyclobenzaprine Desipramine 

Diazepam Diltiazem Dihydrocodeine Donepezil Fenfluramine 

Fluoxetine/ 

Norfluoxetine Gemfibrozil Hydrocodone Hydromorphone Hydroxyzine 

Imipramine Labetalol Lorazepam Meclizine Metoprolol 

Midazolam Morphine Nizatidine Nordiazepam Nortriptyline 

Oxycodone Oxymorphone Oxazepam Pantoprazole Paroxetine 

Pentobarbital Phenytoin Phentermine Propranolol Propoxyphene/ 

Norpropoxyphene 

Ranitidine 

Sertraline/ 

Desmethylsertraline 

Sildenafil/ 

Desmethylsildenafil Temazepam Theophylline 

Trazodone Triamterene Trimethoprim Verapamil/ 

Norverapamil 

Nonprescription Drugs 

Acetaminophen Brompheniramine Cetirizine Chlorpheniramine Dextrorphan 

Dextromethorphan Diphenhydramine Doxylamine Ephedrine Hydrochlorothiazide 

Naproxen Lansoprazole Lidocaine Omeprazole Pheniramine 

Phenylpropanolamine Phenyltoloxamine Pseudoephedrine Quinine Salicylate 

*

Depending upon the formulation and doses of these drugs in a particular pharmaceutical preparation, some of these drugs may fall in more than 

one category—that is, a drug may fall in the controlled substance, prescription, and/or non-prescription category.
8 5 

Table V. Toxicological Findings and Medical Histories of 11 Fatally Injured Obese Aviation Accident* 

Pilots With Elevated Glucose and HbA1c Concentrations 

Glucose (mg·dl−1

) 

Number 

Vitreous 

Fluid 

Urine 

Blood HbA1c (%) 

Drugs Found in 

Biological Samples† Medical History 

1 45 189 —‡ Diltiazem Diabetes controlled by 

hypoglycemic drugs 

2 147 65 — Nizatidine — 

3 109 — 4.5 — — 

4 125 — 6.3 Diphenhydramine 

Chlorpheniramine Diabetes controlled by diet 

5 — 1,438 — — Diabetes controlled by diet 

6 31 333 4.7 

Hydrocodone 

Dihydrocodeine 

Hydromorphone 

— 

7§ 301 6,050 12.4 Phentermine Diabetes controlled by insulin 

and by oral hypoglycemic drugs 

8 16 264 5.3 Midazolam — 

9 — 1,750 — — Diabetes controlled by diet 

10 — 369 5.8 Diltiazem Diabetes controlled by 

hypoglycemic drugs 

11 — 5,700 — — — 

*

In none of these accidents, pilot's health and/or medical conditions were the cause/factors, as determined by the NTSB. 

†

Where possible, based upon multi-analyses in at least two different sample types. 

‡

No analysis, negative findings, no drugs found, or no medical history. 

§

BMI: 39.33 kg·m−2.
9 

Reported Medications

Of the 311 aviators, 208 had not reported taking any 

medications to their aviation medical examiners (AMEs); 

103 reported taking medication(s).The medications aviators reported to their AMEs were those used in treating 

hypertension and diabetes and in reducing cholesterol 

and stomach acid levels. At least one drug of these four 

groups of medications was the most often reported by 

78 of the 103 pilots.

Cause or Contributing Factor

The NTSB concluded that physical impairment of 

pilots, including fatal cardiovascular events, was a cause 

or factor in 23 of the 311 accidents. Additionally, impairment of pilots caused by the use of ethanol/drugs 

was determined to be a cause or factor in 32 accidents.

Aircraft-assisted suicide was found the cause of four accidents. The remaining accidents in which the aviator 

was found positive for ethanol/drugs were attributed to 

adverse weather conditions, mechanical malfunction, 

and/or pilot error.

Discussion

Biological samples from 93% of the fatally injured obese 

pilots were submitted to CAMI for toxicological evaluation. This percentage is comparable to that of a previous 

study (15); accordingly, samples from approximately 80% 

(73–92%) of the pilot fatalities of aviation accidents that 

occurred during the period of 1990 to 2000 were submitted to CAMI. In general, the spectrum of drugs found in 

the obese pilots was similar to those reported earlier with 

civil aviation accident pilot fatalities wherein selective 

serotonin reuptake inhibitors (1) and antihistamines (33) 

were present. A similar drug usage pattern was notable 

in epidemiological studies conducted for the period of 

1989–2003 for fatally injured aviators involved in aviation accidents (6, 8, 13). Findings of the present study 

were clearly indicative of the obesity comorbidities such 

as diabetes, depression, hypertension, and cardiovascular 

conditions, and the findings were consistent with the 

medical conditions mentioned in the medical certification 

examination records of the obese pilots. Obviously, many 

of the medications were taken for the medical conditions 

associated with obesity. Medical conditions—such as 

cardiovascular disease, depression, diabetes, and hypertension—have been linked to obesity (4, 5, 24, 34).

Drugs, including appetite suppressants and antidepressants (23, 38) used for reducing body weight, were 

found in the pilots, as well. For example, phentermine and 

fenfluramine were detected in four aviators, phentermine 

in three, and bupropion in two, though fenfluramine has 

now been withdrawn from the drug markets due to its side 

effects, heart valve conditions, pulmonary hypertensions, 

and cardiac fibrosis (32). Other antidepressants—citalopram, fluoxetine, paroxetine, and sertraline—were also 

found in the obese pilots. Since pilots are a subset of the 

general population, the obesity-related medications taken 

by the aviators could obviously be the case with any group 

of obese people.

The presence of anticonvulsants, atropine, lidocaine, 

and narcotic analgesics in the aviators could be associated 

with the administration of these drugs by emergency health 

care providers at accident scenes or at hospitals for pain 

management, resuscitation, seizure control, and/or surgical 

procedures. Whereas other substances—ethanol, amphetamine/methamphetamine, antidepressants, cardiovascular 

agents, cocaine, sympathomimetics, and THC—were 

taken by the pilots prior to the accidents. Many of these 

substances influence the central nervous system and can 

impair performance, including motor skills.

Obesity may cause diabetes (34). This does not necessarily mean that an obese person is diabetic or that the 

diabetes of an individual may not be controlled by diet, 

exercise, and medications.The current findings suggested 

that the number of pilots with elevated concentrations of 

vitreous and/or urine glucose and/or HbA1c is low—that 

is, 11 (1.2%)—which is supportive of a previous study 

wherein also low numbers (3.2% of 1,335) of fatally injured pilots of civil aviation accidents (1998–2005) were 

reported to have elevated vitreous/urine glucose and/or 

HbA1c levels (11).The drugs found in these 11 obese pilots 

were a heart medication, a benzodiazepine, antihistaminics, and narcotic analgesics. A weight-reducing drug was 

found in one case wherein glucose and HbA1c levels were 

considerably elevated.

It is true that obesity in the general population is increasing with diabetes and continues to be a public health 

concern (9, 20, 26), and this aspect is also true with pilot 

population (30, 35). The obesity associated obstructive 

sleep apnea may lead to daytime sleepiness, which in turn 

may adversely affect neurological functions (27). One of 

the other comorbidities of obesity is depression (2, 4, 5, 

27, 34). These abnormalities, including sleepiness, may 

lead to performance impairment.An obese individual may 

have difficulty in effectively manipulating the controls, 

particularly in the confined space of a flight deck. The 

NTSB determined that health/medical conditions and the 

use of ethanol/drugs were the cause/factors in 55 (18%) 

of the 311 accidents; aircraft-assisted suicide was the cause 

of four accidents. The growing concern with the medical 

issues related to obesity emphasizes the importance of 

addressing, understanding, and potentially resolving this 

aeromedical issue. This could be effectively achieved by 

implementing obesity-related educational programs for 

aviators and aviation medical examiners.The monitoring 
10 

of obesity and diabetes by the aviation medical community 

and the understanding of potential implications of these 

medical conditions with respect to flight safety are also 

crucial. In the aviation community, the obesity-linked 

abnormal neurological and cognitive functions represent 

a potential safety concern.

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