1.

4.

5.

REFERENCES

Booze, C. F. Characteristics of medically disqualified airman
applicants during calendar year 1972. FAA Office of Aviation Medicine
Report No. FAR-AM-74-5, 1974.

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

Dark, S. Characteristics of medically disqualified airline :
pilots. FAA Office of Aviation Medicine Report No. FAA-AM-83-5, 1983.

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. .FAA~AM-78-38, 1978.

Ridera, G. J. Clinical aspects of commercial aviation medicine.
J. Am. Med. Assoc., 201:242-246, 1967.

Lavernhe, J., J. Pasquet, and A. Mathivat. Incidence of cardio-
vascular diseases among the flight deck personnel of an airline.
Aerosp. Med., 40:62-63, 1969.

Orford, R. R., and EZ. IT. Carter. Pre-employment and periodic physical
examination of airline pilote at the Mayo Clinic, 1939-1974.
Aviat. Space Environ. Med., 47(2):180-184, 1976.

Preston, F. S. Twelve year survey of airline pilots.
Aerosp. Med., 39:312-314, 1968.

U.S, GOVERNMENT PRINTING OFFICE: _1984-461-816/10177

16


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MEDICALLY DISQUALIFIED AIRLINE PILOTS

INTRODUCTION

Federal Aviation Regulations (FAR's) require that pilots for scheduled and
nonscheduled airlines possess a first-class medical certificate in order to
exercise the privileges of their air transport pilot certificate. Airline
pilots are required to obtain 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). If
the medical standards are not met, the application for first-class certifi-
cation is denied. This denial can result from any of several levels of
certification review, from the aviation medical examiner (AME) to the Federal
Air Surgeon.

During the time period of this study, Federal Aviation Regulations, Fart
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:

1. A personality disorder that is severe enough to have repeatedly
manifested itself by overt acts.

2. A psychosis.

3. Alcoholism.

4. Drug dependence.

5. Epilepsy.

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

7. Myocardial infarction.

8. Angina pectoris or other evidence of coronary disease that may be
expected to lead to myocardial infarction.

9. Diabetes mellitus that requires insulin or any other hypoglycemic
drug for control.

The above conditions represented the causes for a --~iatcry denial, A
general deaial was issued, under FAR Part 67, for any otner organic, func-
tional or structural disease, defect or limitation that the Federal Air
Surgeon finds makes the applicant unable to safely perform the duties or exer-
cise the privileges of the airman certificate that he/she holds or for which
he/she is applying; or may reasonably be expected, within 2 years after the
finding, to make him/her 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.

Descriptive studies of airline pilot populations have shown the rate of
medical disqualification to be minimal before the age of 45 years but to
increase rapidly thereafter, with cardlovascular diseases responsible for more
than half of the dramatic rise in incidence of disease after age 45. The
Orford and Carter study (7) and many others have already emphasized this
problem of aging pilots and the increased risk of cardiovascular disease.
Orford and 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


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AME Denial

1 27.3

General Denial
Regional Flight Surgeons Deniai

Federal Air Surgeon Denial

Exemption Denial / Final Denial
(FAR 67.!9)

Mandatory Denial / Final Denial

Administrative or Legal Denial

Exemption / Special !ssuance
Issued -Later Terminated

Denial for Failure to Provide
Additional Information
(FAR 67.31)

Percent of Tota! Denials

Figure 1. Final (highest) level of denial.



aA tN a a a eS ee

NE AATLAT AN Te ae Fat awa te ee ee eee . ie

Denials may be made at several levels within the FAA and/or by the AME.
The final level of denial is, however, the one recorded cn a pilot's medical
records. Of the 842 airline pilot denials, 27.3 percent were general denials
issued by the AMCB; 19.4 percent were AME denials (some of these denials could
have been for the "mandatory" conditions that were never appealed by the
applicant); 18.4 percent were administrative or legal denials by the AMCB;
11.6 percent were exemption denials; 8.6 percent were Federal Air Surgeon
denials; 5.1 percent were mandatory denials by the AMCB which were not
appealed to a higher level; and 4.7 percent were denials under FAR 67.31 for
failure to provide additional information (see Figure 1).

As of December 31, 1976, there were 32,080 airmen between the ages of 25
and 59 who listed their occupation as airline pilot. As of January 1, 1982,
there were 842 airline pilots who had been denied first-class medical certifi-
cation during the past 10 years. These denials represent final denials; i.e.,
certificates were not issued at a later date.

The annual denial rate for airline pilots is, therefore, 2.6 per 1,000
active airline pilots, increasing from a rate of 0.4 in the 25-29 age interval
to 10.9 in the 55-59 age interval (see Table I and Figure 2). The mean age of
active (issued) airline pilots is 41.6 years, compared with a mean age of 51.6
for denied airline pilots.

Data on denials by airline employers provide some interesting insights,
even though fraught with limitations that make comparison difficult; i.e.,
small numbers substantially affect comparison (see Table II). Of interest,
however, is that the larger employers, many of which have/had their own med-
ical facilities, have lower denial rates than the smaller employers. Preston
(8) and others (1,3,4) found the same lower rates for larger airlines. Part
of this difference is undoubtedly due to the preventive medical programs of
the larger employers and their assumed association with other organizations’
prevention and rehabilitation programs. Ancther part of the difference is
likewise due to early recognition and removal from flight status of those
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 whom to choose when initially employed. The relative risk of medical
certification denial for those pilots flying for airlines with no medical
facility or cooperative agreement with a medical facility was twice the rate
as for those pilots flying for airlines with some kind of in-house medical
supervision.

Table III shows annual age-cause-specific denial rates increasing to the
highest rate at age interval 55-59 (14.2 per 1,000 active airline pilots).
The rate of medical disqualification is minimal before the age of 45 years but
increases rapidly thereafter (from a rate of 1.4 at the 40-44 age interval to
4.1 at the 45-49 age interval).

Observed in the age-cause-specific annual denial rates is a rapid increase
of cardiovascular denials after age 45. Nothing significant is found in the
25-29, 30-34, and 35~39 age intervals; however, in the 40-44 age interval,
alcoholism and cardiovascular diseases (myocardial infarction, coronary artery
disease, and bypass surgery) begin to be reflected. Cardiovascular causes for
denial begin to increase rapidly in the 45-49 age interval, with myocardial


years. Lavernhe's opinion (6) was that the considerable increase in coronary
risk with age warrants examination particularly intended to detect coronary
disease among older pilots.

This is a descriptive study of medical disqualifications in the airline
pilot population over a 10-year period (1972 through 1981).

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 med-
ical data generated by the aeromedical certification and related programs.

The AMCB's computerized medical records provide historical data for both
daily screening of documen input and epidemiologic/research purposes. This
computer file contains the most recently submitted medical applications for
pilots, whether the certificate was issued or denied or the case is pending.

The airline pilot denial data were obtained from the computer file as of
January 1, 1982, for a 10-year period preceding that date. The active airiine
pilot population as of December 31, 1976 (the mid-period date), was used for
rate computation and comparison.

Airline pilots were identified by the applicant's response in the
occupation block of the FAA medical application. The occupation of airline
pilot, defined as pilot for scheduled and nonscheduled airlines only, includes
captain, co-pilot/first officer, and second officer with a first-class medica)
certificate.

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 10lding an air transport pilot rating and engaging in air
carrier operations.

Prevalence data regarding pathology represent conditions cited as cause
for denial, not number of airline pilcts.

FINDINGS AND DISCUSSION

Observations on the airline pilot group probably come closest to a true
reflection of incidence of disqualifying disease as is possible to observe.
Prescreening by airline companies before employment and FAA requirements for
issuance of a first-class medical certificate result in this group's being
essentially purged of disease prevalence that contributes to higher rates for
other groups. Also, because of occupational/economic reasons, these individ-
uals are less likely to remove themselves voluntarily from followup observa-
tion for known medical conditions that would preclude FAA medical certifica-
tion. Conversely, voluntary attrition is a more frequent occurrence among
nonoccupationally connected pilots who recognize that they are not medically
qualified and, therefore, are never heard from again by the FAA.


Coronary Artery Disease

Myocardial Infarction

Use of Disqualifying Medication
(62 % for Cardiovascular Disease)

Hypertension with Medication

Coronary Artery Bypass Surgery

Other Heart Pathology (Includes
abnormal ECG, coronary
insufficiency, open heart surgery)

Alcoholism

Failure to Provide Additional
Information (FAR 67.31)

Psychoneurotic Disorders

Disturbance of Consciousness

Vascular -Brain (Includes occlusion,
stroke, aneurysm, hemorrhage )

PERCENT OF TOTAL CAUSES*

¥65 % of total causes for denial

Figure 5. The most frequently occurring causes for denial.

15



The overall highest causes for denial by pathology series are: (i) car~
diovascular; (1i) neuropsychiatric; and (iii) the miscellaneous category,
which includes endocrinopathies, general systemic conditions, use of disquali-
fying medication, and deniais for failure to provide additional medical infor-
metion, with annual rates per 1,000 active pilots of 1.7, 0.6, and 0.6 respec-
tively. Cardiovascular causes account for almost one-half (49.3 percent) of
ail causes for denial. .

The highest causes for denial by specific pathology are: (i) coronary
artery disease; (11) myocardial infarction; (iii) use of disqualifying medica-
tions (62 percent of these were also denied due to cardiovascular pathology);
(iv) hypertension with medication; and (v) coronary artery bypass surgery.
These five specific cauges account for 46 percent of all causes for denial.

Lower denial rates were found for the larger employers, many of which
have/had their own medical facilities. Pilots flying for airlines with no
medical facility or cooperative agreement with a medical facility are denied
twice as often as those pilots who fly for airlines with some xind of in-house
medical supervision.

On the basis of thege and previcus findings regarding airline pilots, it
is evident that maintenance of high standards of safety requires close cardio-
vascular supervision as these pilots grow older.


FAA~AM~84-3

MEDICALLY DISQUALIFIED AIRLINE PILOTS

Civil Aeromedical Institute
Federal Aviation Administration
Oklahoma City, Oklahoma .«@

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a Shirley J. Dark
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August 1984

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

' Prepared for “4
- U.S. DEPARTMENT OF TRANSPORTATION
Federal Aviation Administration

Office of Aviation Medicine
Washington, D.C. 20591

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Tabie I. AGE DISTRIBUTION OF AIRLINE PILOTS

Active Denied Annuai
Age Groups Airline Pilots Airline Age-Specific
(12-31-75) Pilots Denial Rate*
25-29 1,551 6 0.4
30-34 4,973 9 0.2
35-39 7,730 37 0.5
40-44 6,681 80 1.2
45-49 4,070 121 3.0
50-54 3,604 209 5.8
55-59 3,471 380 10.9
TOTAL 32,080 842 2.6

*Rate per 1,000.

Note:

The annual finai denial rate for all first-class medical
certificate holders is 2.8; 3.1 for second-class medical
certificate holders; 7.1 for third-class medical certificate
holders; and 6.1 for all classes of medical certificates.


infarction highest; coronary artery disease second; use of disqualifying medi-
cations third (about two-thirds of these are directly related to car¢io-
vascular disease); hypertension with medication fourth; and coronary ertery
bypass evrgery ranking fifth. Cardiovascular diseases continue to increase
and to represent the highest cause for denial in age intervals 50-54 and 55-59
(see Tables III and IV).

The overali highest causes for denial by pathology series are: (1) car-
diovascular; (ii) neuropsychiatric; and (411) the miscellaneous category which
includes endocrinopathies, general systemic conditions, use of disqualifying
medications, and denials for failure to provide additional medical informa-
tion, with annual rates per 1,000 active airline pilots of 1.7, 0.6, and 0.6
respectively. Cardiovascular causes account for almost one-half (49.3 per-
cent) of all causes for denial (see Figures 3 and 4 and Tables III and IV).

The highest causes for denial by specific pathology are: (1) coronary
artery disease; (11) myocardial infarction; (111) use of disqualifying medica-
tions; (iv) hypertension with medication, and (v) coronary artery bypass sur-
gery. These five specific causes account for 46 percent of all causes for
denial (see Figure 5 and Table V).

Of the 112 denials for use of disqualifying medicaticn, 69 (62
percent) were also denied because of cardiovascular problems. Of the 80
denials for hypertension with medication, 35 (44 percent) were also denied for
disqualifying medication. Of the 125 denied for coronary artery disease, 53
(42 percent) were also denied due to coronary artery bypass surgery. Of the
119 denied for myocardial infarction, 26 were also denied for coronary artery
disease and 9 for coronary artery bypass surgery.

Six hundred and twenty-seven pilots were denied for a single cause, 185
for two causes, and 30 for three causes.

The Air Line Pilots Association (ALPA) states that it is part of an air-
line pilot's professional responsibility to recognize that any departure from
good health status represents a threat to flight safety (4). Therefore, as
suggested in the Orford and Carter report, pilots should be encouraged to
report symptoms of disease, particularly cardiovascular and neuropsychiatric.
This requires education to the effect that failure to report symptoms to avoid
losing their jobs may actually result in an unnecessary termination of their
careers.

This and other studies 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 close cardiovascular supervision after
pilots reach 45 years of age.

SUMMARY

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


ceo one nm

Acknowledgment

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

{ Acce

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Cardiovascular

Neuropsychiatric

Miscelianeous (Includes
Endocrinopathies, etc.)

Eye

Ear, Nose, Throat
Abdominal (Mostly GI,GU)
Bones and Joints
Respivatory

Muscles

Annual Rate per 1,000 Active Airline Pilots

TOTAL CAUSE FOR DENIAL RATE - 3.4

Figure 3. Denial rates by major body system (cause).

il

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Cardiovascular

Miscellaneous (Includes
Endocrinopathies, etc.)

Neuropsychiatric
Bones and Joints
Ear, Nose, Throat
Eye

Abdominal (Mostly GI, GU)

Respiratory

Muscles 0.4

PERCENT OF TOTAL CAUSES

Figure 4. Cause for denial by major body system.

13

nm em oe ee ee ee


Cae as

Technical Report Documentation Page

T. Report No. 2. Government Accession Now 3 Recipreat’s Catalog No.
FAA~AM-84~ 9 Ad-AIY4 454
4, Title and Subtitle 5. Report Date

&. Performing Orgenizotion Code

MEDICALLY DISQUALIFIED AIRLINE PILOTS

18. Performing Organization Report No.

7. Auther!s)

Shirley J. Dark

9. Ferforming Organization Neme and Address 10. Work Unit No. (TRAIS)
FAA Civil Aeromedical Institute

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

Oklahoma City, Oklahoma 73125

13. Type of Report and Period Covered

12. Sponsoring Agency Name and Address
Office of Aviation Medicine
Federal Aviation Administration

800 Independence Avenue, S.W. 14. Sponsoring Agency Code
Washington, D.C. 20591

15. Supplementary Notes

\ ee

16. Abstroct
-Observations on the airline pilot group probably come as close to a true reflection
of incidence of disqualifying disease as is possible to observe. Prescreening by
airline companies before employment and the FAA's requirements for issuance of a
first-class medical certificate result in this group's being essentially purged of
disease prevalence that contributes to higher rates for other groups.> Also, because
of occupational/economic reasons,Aghese individuals aregless likely to voluntarily

remove themselves from followup observations for known medical conditions that could
preclude FAA medical certification. [4:, s7y dg €xa nue ey

“HeCmedical records of airline pilots medically disqualified by the FAA over a 20-
year period ,were~examined. >Date of birth, employer, date of disqualification, and
reason for disqualification were recorded for each pilot. The data represent the
final action taken on each pilot for a particular examination. Deeng this periods S42

perted. Cardiovascular diseases represent the highest cause for deniai, with age
being a major factor in the incidence of cardiovascular disease.in this airline pilot

group. * Denials for cardiovascular reasons account for 50% of ali denials in this
group.
FAA medical certificate denial is minimal before age 45 but increases rapidly there-

after, with cardiovascular diseases responsible for more than half of this dramatic
rise in incidence of disease. Maintenance of high standards of safety requires close
ee

Sight-hundred-and fortystwdvairline pilots were medically disqualified @uriag this |

ae

SD

js

17, Key Words 48. Distribution Statement

Airline Pilots Boeument is available to the public

Medical Certification Denial through the National Technical
Information Service, Springfield,
Virginia 22161

| 19. Security Classif. (of this report) | DW. Security Clossif, (of this poge) ~f-ae No.of Pages | 22. Price
| ‘Unclassified | Unclassified 16

—

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

\e

|



Bt

NOTICE

This document is disseminated under the sponsorship of

the Department of Transportation in the interest of
information exchange. The United States Government assumes
no liability for its contents or use thereof.

. a



Table 11. AIRLINE PILOT DENIALS BY EMPLOYER

Annual Rate Percent of

Employer Per 1,906 Total Denials
Airlift International 17.7 2.0
Airwest/Hughes 2.4 1.4
Allegt.eny Airlines 2.3 2.5
American Airlines* 1.2 4.7
Braniff International Airways 3.5 5.5
Continental Airlines® 1.4 17
Delta Air Lines 2.6 9.4
Eastern Air Lines* 2.2 9.6
Flying Tiger Lines 4.7 2.3
Frontier Airlines 3.3 1.9
National Airlines 5.4 3.7
Northwest Airlines* 0.8 1.3
Ozark Air Lines 1.4 0.6
Pacific Southwest Airlines 2.8 0.7
Pan American World Airways* 3.6 10.2
Republic Airlines* ,** - 1.9
Seaboard ¥rld Airlines 11.0 1.9
Texas International Airlines 8.3 2.3
Trans World Airlines* 1.8 7.2
United Airlines* 1.3 7.7
Western Airlices 2.3 3.1
Other Airlines 18.5
TOTAL 100.0

* Asterisks indicate those airlines that have/had their own

medical facilities or cooperative agreement with a medical
facility.

#£ No population data available.



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