DOT/FAA/AM-01/11

Edna Fiedler

Daniel R. Orme

William Mills

Civil Aerospace Medical Institute

Federal Aviation Administration

Oklahoma City, Oklahoma 73125

John C. Patterson

School of Aerospace Medicine

2507 Kennedy Circle

Brooks Air Force Base, Texas 78235

July 2001

Final Report

This document is available to the public

through the National Technical Information

Service, Springfield, Virginia 22161.

Assessment of Head-Injured

Aircrew: Comparison of

FAA and USAF Procedures

Office of Aerospace Medicine

Washington, DC 20591

U.S. Department

of Transportation

Federal Aviation

Administration
NOTICE

This document is disseminated under the sponsorship of

the U.S. Department of Transportation in the interest of

information exchange. The United States Government

assumes no liability for the contents thereof.
i

Technical Report Documentation Page

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

DOT/FAA/AM-01/11

4. Title and Subtitle 5. Report Date

Assessment of Head-Injured Aircrew: Comparison of FAA and USAF July 2001

Procedures

6. Performing Organization Code

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

Fiedler, E.R., Orme, D.R., Mills, W.1, and Patterson, J.C.2

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

1

FAA Civil Aerospace Medical Institute

P.O. Box 25082

Oklahoma City, OK 73125

2

School of Aerospace Medicine

2507 Kennedy Circle

Brooks Air Force Base, TX 78235

11. Contract or Grant No.

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 subtask AM-B-01-HRR-517.

16. Abstract

The Federal Aviation Administration and the United States Air Force are similarly charged with determining

whether aviators who have sustained head injuries are medically qualified to return to flying. The purpose of

this paper is to first explain the major differences in missions between the USAF and the FAA, and then

outline these procedures and rules, note their similarities and differences, address the strengths and

weaknesses of each approach, and discuss the possible reconciliation of these differences. Finally, brief case

material are presented to illustrate both evaluation methods.

17. Key Words 18. Distribution Statement

Aviators, Pilots, Traumatic Head Injury, CogScreen Document is available to the public through

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 10

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

1

ASSESSMENT OF HEAD-INJURED AIRCREW:

COMPARISON OF FAA AND USAF PROCEDURES

Traumatic brain injury (TBI) frequently results in

symptoms that are of aeromedical concern. Neuropsychiatric symptoms associated with TBI are wideranging but can be broadly categorized into three

major areas (4). Cognitive difficulties are evident in

slowed information processing speed and efficiency,

reduced concentration, and memory problems. Emotional changes typically present as either exaggerated

or blunted emotional responsiveness; anxiety and

depression are also commonly found in this population. Finally, because of reduced executive functioning, TBI patients may have deficient self-awareness,

reduced planning skills, and difficulty with impulse

control. Besides neuropsychiatric symptoms there

also may be focal neurological deficits, depending

upon lesion location, and an increased risk for seizures. Annegers, Grabow, Groover (1), for example,

noted that 12%, 2%, and 1% of patients with severe,

moderate, and mild TBI, respectively, experienced

post-traumatic epilepsy requiring anticonvulsant

medication within five years of injury. Feeney and

Walker (2) developed a mathematical equation that

can be used to predict the probability of post-traumatic seizures taking into account several risk factors.

Consequently, when pilots sustain TBI it is important that they undergo extensive evaluations to determine whether they are capable of managing the

complex cognitive and psychomotor demands of

flying. The burden of oversight of these evaluations

falls to the Federal Aviation Administration (FAA)

for private and commercial pilots, and the United

States Air Force (USAF) for USAF pilots. Thus, both

organizations (FAA and USAF) are similarly charged

with ensuring the aeromedical fitness of pilots who

return to flying following TBI. However, the missions of the USAF and the FAA are different and

therefore the evaluation procedures and rules that

allow for a pilot’s return to flying differ. The purpose

of this paper is to first explain the major differences

in missions, and then outline these procedures and

rules, note their similarities and differences, address

the strengths and weaknesses of each approach, and

discuss the possible reconciliation of these differences. Finally, brief case material will be presented to

illustrate both evaluation methods.

MISSIONS AND PHILOSOPHY

Both the FAA and USAF share the goal of safe

flying. While both the FAA and USAF medical communities have the same responsibility of overseeing

pilot evaluations, their missions vary significantly.

USAF medical personnel conditions must consider

continuous worldwide readiness and unexpected deployments, thereby including not only safety but also

the military mission. It needs to be remembered that

military pilots must sometimes work in “austere

environments.” Such environments may include long

missions, substantial and frequent g-forces, vigilance

for prolonged periods of time not only to the workings of the aircraft but also possible hostile forces,

and the stresses of combat and sustained periods of

separation from family. Pilots, then, must be in

excellent health and there is little room for compromise. Pilots who sustain moderate and severe TBI

must demonstrate no residual deficits on neurological or neuropsychological examinations before being

allowed to resume flying duties. From a neuropsychological perspective, any evidence of cognitive skill

decline is sufficient to result in DNIF (Duties Not to

Include Flying).

The FAA mission does not take into account

worldwide readiness or military mission requirements.

The FAA makes decisions concerning medical qualification for the duration of the medical certificate,

which can vary from six months to three years. This

means the aviation medical examiner who does the

general examination, any neurologists who are consulted, and the FAA physician who makes the final

decision, will focus on a specific time frame. Nor

does the FAA have a military mission. The FAA must

balance the needs and desires of the applicant against

the risks to society. “The FAA recognizes that individuals should be allowed the maximum freedom of
2

choice, consistent with safety in air commerce, in

deciding the extent to which their exercise of airman

privileges should be limited by their personal health”

(FAR 67.401 (e) for private pilots). Consistent with

this viewpoint, the FAA has to balance the impact of

neurological conditions with whether the pilot has a

first-class (airline transport pilot), second-class (other

commercial), or third-class (private pilot) medical

certificate.

The commercial or airline transport pilot has to

consider the life or property of others. In these cases,

the importance of even a small risk for an incapacitating medical event must be considered. The Federal

Air Surgeon of the FAA must establish medical standards for airline transport pilots that provide the

highest possible degree of safety for the public. The

FAA’s Aeromedical Certification Division has the

option of issuing a limited second- or third-class

certificate, but there is no option for issuing a limited

first-class certificate. This could be “valid only for a

fully qualified two-pilot crew,” “valid for agricultural

duties only,” or etc. Although seldom used for TBI,

it is frequently used in cardiac cases.

The private pilot is not performing in a job that

requires providing safe transportation of the public

or the public’s property. Part 67.401.e allows the

private pilot “to accept reasonable risks to his or her

person and property that are not acceptable in the

exercise of commercial or airline transport pilot privileges, and, at the same time, considers the need to

protect the safety of persons and property in other

aircraft and on the ground.”

DEFINITIONS AND PROCEDURES

Rules governing physical qualifications for civilian flying duties are found in Federal Aviation Regulations (FAR) Title 14 of Code of Federal Regulations

(CFR) Part 67 Medical Standards and Certification

(Part 67), and, for Air Force aviators, Air Force

Instruction (AFI) 48-123 and Waiver Guidelines.

The interested reader should consult these for definitive guidance. Much of the content of this paper is

derived from these standards.

Medical certificate categories

There are three classes of medical certificates that

qualify individuals for civilian flying duties: firstclass, second-class, and third-class. A first-class airman certificate is needed to receive an airline transport

pilot certificate. A second-class medical certificate is

required for a commercial pilot, flight engineer, flight

navigator, or Air Traffic Control Specialist (ATCS),

not including FAA employee ATCSs. Finally, a thirdclass medical certificate is for private, recreational, or

student pilots (Part 67-11 of Title 14 of the Code of

Federal Aviation Regulations; 14 CFR, amendment

67-11). Glider and Free Balloon Pilots do not require

a medical certificate of any class. Neurological standards for a first-class, second-class, and third-class

airman medical certificate are the same (CFR, Part

67.109).

For USAF aviators, there are also three medical

classes that qualify for flying duties. They are: Flying

Class I (FC-I) for entry into pilot training; Flying

Class II (FC-II) for individuals who are in pilot

training, rated officers, and physicians who are Flight

Surgeons; and Flying Class III (FC-III) for non-rated

individuals whose duties involve flying. These include, for example, boom operators, crew chiefs, and

load masters.

Waiver consideration

Once medically qualified for flying, aviators sometimes acquire illnesses or injuries that render them

medically disqualified. Head injuries can be disqualifying for both civilian and USAF pilots. However,

there are occasions when head-injured aviators can

return to flying. This requires a request for a waiver

of the medical condition. For civilian aviators, factors that are considered in the waiver process include:

• any current or recent neurological symptoms or

neurological or other medical findings

• the availability of an explanation for the cause of the

problem that is acceptable in terms of risk for future

recurrence

• any recognized factors involving the risk of future

adverse neurological events or of other adverse events

• the anatomic integrity and functional status of the

nervous system as determined by appropriate evaluative techniques

In the USAF, standards for consideration of waiver

are remarkably similar. Overriding considerations

are that the medical condition should:

• not pose a risk of sudden incapacitation

• pose minimal potential for subtle performance decrements, particularly with regard to the higher senses

• be resolved or be stable and be expected to remain so

under the stresses of the aviation environment
3

• if the possibility of progression or recurrence exists,

the first symptoms or signs must be easily detectable

and not pose a risk to the individual or the safety of

others

• cannot require exotic tests, regular invasive procedures, or frequent absences to monitor for stability or

progression

• must be compatible with the performance of sustained flying operations in austere environments

Head-injured fliers usually do not meet these general standards. There is concern for potential seizures

and this presents a “risk of future adverse neurological events” or “risk of sudden incapacitation.” Also,

they may sustain a decline in cognitive skills that, for

mild head injuries, may not be immediately apparent

in a clinical interview or physical examination but

may be evident upon neuropsychological evaluation.

This represents “current neurological symptoms” and

the “potential for subtle performance decrements.”

With experienced fliers who have very mild deficits,

it could be reasoned that their duties involve overlearned skills and that their cognitive deficits are so

subtle as to not interfere with their duty performance.

While this may be true for routine flights, “sustained

flying operations in austere environments” and aircraft emergencies present altogether different situations where cognitive abilities must function at peak

levels. Consequently, even mild deficits may be incompatible with flying duties. A request for a waiver

of medical condition is submitted when these general

and other specific standards are met.

Medical specialists

The FAA relies heavily on aviation medical examiners (AMEs), community physicians designated by

the FAA to complete medical evaluations. These

physicians work out of their own offices or designated places of employment. The AME is given the

authority to accept applications and perform physical

examinations necessary to determine qualifications

for the issuance of second- and third-class FAA airman medical certificates under and in accordance

with 14CFR67 and the 1999 Guide for Aviation

Medical Examiners (FAA, 1999). The senior aviation

medical examiner (SME) has the additional authority to determine qualifications for the issuance of

first-class FAA airman medical certificates under and

in accordance with 14CFR67. Final decision-making

rests with the FAA Federal Air Surgeon and his staff,

not in the neurologists or neuropsychologists who do

the evaluations.

Medical management of USAF aviators is the duty

of flight surgeons. All flying units have flight surgeons assigned to them, and they are on flying orders

that require them to average at least four hours of

flying per month. Flight surgeons act as general

medical officers to their assigned flying squadrons

and, when their flying unit deploys, deploy with

them. In this manner, they are intended to have

intimate knowledge of not only aviation but also of

the flying communities to which they are assigned.

The oversight of waiver recommendations is always

the responsibility of flight surgeons and, ultimately,

the decision whether to grant a waiver is also decided

by a delegated USAF Surgeon General authority.

This decision is made at different levels (e.g., base,

major command) depending upon the medical condition in question.

Procedures

When fliers sustain TBI they are evaluated by local

AMEs or flight surgeons, for civilian and military

fliers, respectively, who then manage the cases and

submit waiver packages, if necessary. In the FAA

system, the AME performs a physical examination,

obtains a medical specialist’s opinion, if necessary,

and submits a narrative incorporating all of the

pertinent findings to the FAA Civil Aerospace Medical Institute for disposition decisions. When it is

necessary to obtain a specialist’s opinion, the flier

must select a provider and ensure the AME receives a

summary of the findings of that evaluation. The

USAF’s system is more complex. In all cases, a neurological evaluation is required and, for Category 3-

6 head injuries, must be conducted by a neurologist.

While Category 1 and 2 closed head injury (CHI)

evaluations are conducted by the local flight surgeon,

Category 3-5 CHI examinations must be at the

USAF’s Aeromedical Consultation Service (ACS).

Neuropsychological evaluations are also required for

all but Category 1 head injuries and, with the exception of Category 2, these must be conducted at the

ACS. However, the results of neuropsychological

evaluations for Category 2 CHI are still reviewed by

ACS neuropsychologists and recommendations based

on this review are offered. Other medical consultations, if necessary, are arranged by the flight surgeon
4

who is managing the flier’s waiver package or the ACS

and are usually with military providers. ACS evaluation narrative summaries are added to the waiver

package and submitted to the appropriate medical

authority.

TWO CASES

USAF case presentation

The patient was a 34-year-old USAF fighter pilot

with more than 1,500 total flying hours. Playing

pitcher on a softball team, he ran for a pop-up fly and

collided with another player. He struck his right

temporal area against the other player’s head but

sustained no loss of consciousness. Both players fell

to the ground, got back up, and continued to play.

The patient finished the last 30 minutes of the game

but, as the evening and game progressed, became

increasingly confused, irritable, and incoherent. Eventually he began asking teammates, “What are we

doing here?” He did not remember the collision, did

not remember that his wife was in graduate school

and could not recall current events. His wife took

him to the local emergency room. Initially, in the ER,

he could demonstrate only limited short-term

memory; he knew no current events but could remember three objects five and ten minutes after their

presentation. Medical examination revealed a right

temporal abrasion and a normal CT scan. He was

observed in the ER and he slowly regained memory

for events, presidents, etc. About eight hours after the

accident, he was released to go home.

He stayed home over the weekend and was evaluated by a USAF flight surgeon on Monday, two days

after the accident. The pilot still could not recall

anything from the time of injury until 7.5 hours later.

He had no headaches, dizziness, numbness, weakness,

loss of balance, or double vision and, except for some

increased irritability, was otherwise asymptomatic.

Within six weeks after the injury, he was evaluated

at the ACS. As a result of this evaluation he was

diagnosed with moderate head injury and mild reduction in information processing speed and attention/concentration deficits. Along with other

neuropsychological results (see Table 1), his IQ scores

were below those commonly associated with USAF

aircrew and below premorbid estimates of his ability,

based on his performance on the Air Force Officer

Qualification Test (AFOQT), academic, and other

histories. The recommended aeromedical disposition

was to disqualify him from flying duties and for him

to undergo a re-evaluation in two years (in accordance with USAF aeromedical policy at the time).

In the interval (18 months) between evaluations,

he did well in his job, and over the months he and his

family noted a reduction in irritability. He was reevaluated at the ACS, and nearly all scores suggested

improvement. Notably, his overall cognitive scores

were more consistent with premorbid estimates. He

was granted a waiver and returned to flying status.

Had this case occurred more recently, current AF

aeromedical policy would allow him to be evaluated

earlier (six months from the time of injury). Given

the normal CT immediately after the injury and with

neuropsychological test scores showing significant

improvement (e.g., corresponding with premorbid

estimates), he would be recommended for return to

flying (RTF) at the six-month point.

Discussion of USAF case

This is an individual who sustained a relatively

mild injury (e.g., no loss of consciousness). Still,

results of neuropsychological testing suggested subtle

deficits in areas that are consistent with those sustained in TBI, such as reduced concentration and

speed of information processing. It could be argued

that the Full Scale Intelligence Quotient (FSIQ) that

he obtained as a result of his initial evaluation is well

within normal limits, compared to a national normative sample and, in fact, is nearly one standard deviation above the national mean. Based only on FSIQ

(in practice, however, this should never be the case),

the thought could be that he should have been allowed to return to flying duties. However, the mean

FSIQ for USAF pilots is 120.8 with a standard

deviation of only 8.2 (5); his FSIQ score, then, was

lower than is typically seen in aviators. Additionally,

using the patient’s AFOQT score as a measure of

premorbid ability (4), his premorbid FSIQ was estimated to be 121. Altogether, it was reasonable at the

time of the first evaluation to conclude that he had

sustained a decline in cognitive ability. The recommendation not to return him immediately to flying

duties was based on these neuropsychological data

and because he presented some risk for seizure. This

is a conservative approach and reflects the high level

of importance placed on the safety of the individual

pilot and weapons systems; it also reveals the high

level of cognitive efficiency that is thought to be

needed in the operational environment of the military
5

aviator. Additionally, it is important to note that at

reevaluation, he evidenced improvement in nearly all

areas assessed. Spontaneous remission of symptoms

over a period of months is to be expected with patients

who have sustained CHI. It is also noteworthy that,

while he was initially grounded, this pilot was later

determined to be medically fit to return to flying

FAA case presentation

This is a 29 year-old airline transport pilot who

had 1,700 hours of flight time when he was involved

in an automobile accident (AA) as a passenger. He

was ejected through the driver’s side window, which

he broke with his head. He was unconscious for about

five minutes, after which he awakened in a confused

and disoriented state. Neurological exam at the ER

showed improving mental status, some memory loss,

mild facial asymmetry with grimace, and bilateral

Babinski signs. CT and later MRI brain scans revealed multiple cerebral contusions. He had little

retrograde amnesia, but had 12 hours of post-traumatic amnesia. Examination 20 days later revealed

continued word finding difficulty, poor memory,

and slurred speech. About one month post-injury, he

became lost in a local area. A cognitive assessment at

that time involving only a few basic tests revealed

grave difficulties with abstraction and memory. At

two months post-AA, the pilot described a feeling of

being “disconnected” and some memory difficulty.

Formal neuropsychological testing 31⁄2 months postAA showed improvement, with relatively mild defects

in complex attention, psychomotor functioning, and

word retrieval. (See Table 2). At eight months, comprehensive neuropsychological testing, including

CogScreen, revealed continued improvement with a

performance IQ of 112, compared with the previous

score of 95. However some evidence of the previously

mentioned deficiencies remained. The pilot entered

an intensive cognitive retraining program, and the

testing was repeated 12-months post-AA with good

resolution of these deficits. There was mild slowing

of responses on the Grooved Pegboard Test, but

values were within normal limits. Neurological exam

was normal. Repeated EEGs had all been normal.

Fourteen months after his head injury this pilot was

again granted a first-class medical certificate and

began retraining.

Discussion of FAA case

Traumatic brain injury (TBI) is one of the most

challenging aeromedical certification issues because

of the potential for subtle as well as sudden incapacitation and the highly variable timing and degree of

eventual recovery. The FAA has internal guidelines

(periodically revised) regarding certification after TBI,

but each case is always evaluated individually on its

own merits. This case of a commercial pilot with

moderate-to-severe diffuse (multifocal) TBI, without focal neurological deficits or seizures, is fairly

typical. Formal psychometric testing was required over

about a one-year recovery period, there were multiple

FAA physician reviews, and prior to recertification, an

Table 1. USAF Case Data Summary

Wechsler Adult Intelligence Scale – Revised * Paced Serial Addition Test *

1st Eval 2nd Eval Series 1 2 3 4

Verbal IQ 106 127 1st Eval % Correct 94 88 75 56

Performance IQ 118 126 2nd Eval % Correct 98 90 84 68

Full Scale IQ 113 130 Tactual Performance Test

Wechsler Memory Scale – Revised * 1st Eval 2nd Eval

Verbal Memory 101 97 Dominant Hand ** 4’02” 4’05”

Visual Memory 94 108 Nondominant Hand ** 3’44’ 2’51”

General Memory 97 98 Both Hands ** 1’59” 1’48”

Attention/Concentration 105 98 Total Time ** 9’05” 8’44”

Delayed Recall 114 101 Memory * 8 9

Selective Remembering Test * Localization * 1 7

Total Words Recalled 99 127

* higher scores reflect better performance ** lower scores reflect better performance
6

FAA-appointed neurology consultant evaluated the

entire record. The pilot also retained a private aviation medical advocate to assist with his case.

For severe TBI, FAA guidelines recommend applicants should have at least a one-year recovery period and

the condition considered stable by the attending physician. Applicants must provide all hospital/medical

records, a complete neurologic evaluation, and, in most

cases, a neuropsychological evaluation. A single posttraumatic seizure within 24 hours usually requires a

one-year recovery period before consideration for medical certification. A single seizure beyond 24 hours

requires four years, and two or more seizures beyond 24

hours might require ten years of being seizure-free and

off medication. Certification is based on negative neurologic and neuropsychological evaluations and a normal EEG at the end of appropriate recovery period.

Review by a FAA consultant may be required.

In all conditions, follow-up should be accomplished as recommended by the airman’s treating

physician, as recommended by a FAA-selected reviewing consultant, or as deemed appropriate based

on sound medical judgment. CT scans, MRIs, cerebral angiograms, and/or EEG’s may be required as part

of a complete neurologic evaluation in selected cases.

SUMMARY AND CONCLUSIONS

The FAA and USAF are both tasked with oversight

of aviation safety, while the USAF has the additional

responsibility of balancing safety with the necessity

of mission completion. While their approaches to the

evaluation of head-injured aviators are quite similar,

there do appear to be two overriding differences.

These relate to the amount of control maintained

over the evaluation process and the relative emphasis

placed on the autonomy of the individual aviator.

Most evaluations of head-injured USAF aircrew are

conducted by USAF medical specialists who are selected by the USAF for the aviator. Except for the

AME who manages individual FAA cases, civilian

aviators select their own medical specialists. The

USAF, then, maintains greater control over the evaluation process. The FAA, on the other hand, allows

Table 2. FAA Case Data Summary

Weschler Adult Intelligence Scale – Revised * CogScreen – Aeromedical Edition

Scaled Score Index 1st eval 2nd eval

S S

1st eval 2nd eval VSCRTC ** 2.38 2.75

- Digit Span 10 14 SATACRTC ** 0.62 0.50

- Vocabulary 12 13 DATDRTC ** 0.86 0.79

- Arithmetic 11 13 MANACC * 75% 100%

- Object Assembly 10 12 DATSCACC * 75% 100%

- Digit Symbol 13 13 DATIPRE ** 7 7

SATDIFAI ** 2 3

Grooved Pegboard (time in seconds) ** CVLT (words recalled) *

- Right Hand 87 59 - Trials 1 - 5 62 80

- Left Hand 92 66 - Trial 1 8 10

- Trial 5 14 16

- Short Delay Recall 15 16

PASAT (errors) ** 21 2 - Long Delay Recall 15 16

Category (errors) ** 37 7 - Recognition Hits 15 16

* higher scores reflect better performance VSCRTC = Visual Sequence Comparison Speed

** lower scores reflect better performance SATACRTC = Shifting Attention Arrow Color Speed

DATDRTC = Divided Attention Indicator Dual Speed

PASAT = Paced Serial Addition Test MANACC = Manikin Accuracy

CVLT = California Verbal Learning Test DATSCACC = Divided Attention Sequence Comparison Accuracy

DATIPRE = Divided Attention Indicator Dual Premature Responses

SATDIFAI = Shifting Attention Discovery Failures to Maintain Set
7

greater autonomy to the individual aviator. This is

reflected not only in the manner in which specialists

are selected for their evaluations but also in the length

of time required before returning to flying after a

head-injury. Assuming there are no complications,

the USAF requires a five-year wait following a severe

closed head injury, for example, while the FAA requires one year with no complications prior to returning to flying duties.

The cases presented highlight an important point

concerning the evaluation of aviators. Aviators are, in

general, a very high-functioning population. Consequently, a “normal” performance on neuropsychological tests (compared to national standardization

samples) may represent a decline from premorbid

abilities and warrant further investigation. In both

cases presented in this paper, the results of the initial

evaluations were, generally speaking, in the “average”

range. However, subsequent evaluations revealed an

improvement in functioning that was disproportionate to that expected by practice effect alone. This

suggests that an “average” performance most likely

represented a decline for these individuals. A psychologist unfamiliar with characteristic aircrew performance might have concluded after the first

evaluations that there was no impairment or decline

in ability and recommended a return to flying.

It is also important to remember that reduced

functioning as a result of a head injury is selective and

that the skills most affected are often ones that are

critical to competent airmanship such as the rapid

processing of information and working memory. A

summary score, one that incorporates the results of

several subtests (e.g., FSIQ) may mask these deficits

since it consists of scores obtained on different tasks,

some of which are resistant, and others that are

sensitive, to cortical insult.

Should the FAA and USAF merge their procedures? Interestingly, there has already been movement in the world community towards unifying

aeromedical standards. A working group involving

representatives of several countries has developed a

proposed standard for the evaluation of head injured

aircrew that would be used by the militaries of these

countries. This proposal defines various degrees of

head injury and the methods of evaluation required

for a waiver to return to flying. Given this, it could

well be that the FAA and USAF could also develop

unifying standards. Whether this would be to the

advantage of both organizations and their respective

taskings, however, is unclear.

There is movement toward using computer-based

testing, like CogScreen, that is validated for airmen.

In the future, airman-validated testing may eventually allow for a much more efficient evaluation of

head-injured pilots and serve as one vehicle for unifying the FAA and USAF approaches. Current neuropsychological testing is extremely complex and

expensive and could be improved by specific adaptations for defining aviation related abilities.

REFERENCES

1. Annegers J, Hauser WA, Coan SP, and Rocca WA. A

population-based study of seizures after traumatic

brain injuries. N Engl J Med 1998;338:20-4.

2. Feeney DM, and Walker EA. The prediction of posttraumatic epilepsy. Arch Neurol 1979;36:8-12.

3. Lezak M. Neuropsychological assessment. 3rd ed.

New York: Oxford University Press;1995.

4. Orme,DR, Ree MJ, and Rioux P. Premorbid IQ

estimates from a multiple aptitude test battery:

Regression vs. equating. Archives of Clinical Neuropsychology (in press).

5. Orme DR, and Thompson WT. Multidimensional

Aptitude Battery normative data using USAF

pilot training candidates (manuscript submitted

for publication).
8