Assessing the Effectiveness 

of the Conditions AMEs Can 

Issue Program: 2013-2014

Ann I. Norris

Valerie J. Skaggs

Thomas R. Chidester

Civil Aerospace Medical Institute

Federal Aviation Administration

Oklahoma City, OK 73125

December 2015

Final Report

DOT/FAA/AM-15/21

Office of Aerospace Medicine

Washington, DC 20591
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.

___________

This publication and all Office of Aerospace Medicine 

technical reports are available in full-text from the 

Federal Aviation Administration website.
ii

Technical Report Documentation Page

1. Report No.

DOT/FAA/AM-15/21

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

4. Title and Subtitle

Assessing the Effectiveness of the Conditions AMEs Can Issue Program: 

2013-2014

5. Report Date

December 2015

6. Performing Organization Code

7. Author(s)

Norris AI, Skaggs VJ, Chidester TR

8. Performing Organization Report No.

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

FAA Civil Aerospace Medical Institute

P.O. Box 25082 

Oklahoma City, OK 73125 

11. Contract or Grant No.

12. Sponsoring Agency Name and Address

Office of Aerospace Medicine

Federal Aviation Administration

800 Independence Ave., S.W. 

Washington, DC 20591

13. Type of Report and Period Covered

14. Sponsoring Agency Code

15. Supplemental Notes

16. Abstract

Introduction: This paper describes the results from a two-year review of the Conditions an AME Can Issue 

(CACI) monitoring safety assurance process. When an aviation medical examiner (AME) examines an airman 

during the medical certification process, there are conditions for which an AME must defer to Aerospace 

Medicine before the airman's certificate is issued. In 2013, the Office of Aerospace Medicine implemented 

changes for nine specific medical conditions to allow AMEs to process more applicants immediately following 

the examination. This process became known as Conditions an AME Can Issue (CACI). A review was needed 

to document the certification changes over time. 

Methods: Medical certification data from 2013 and 2014 were analyzed to determine the number of CACI- related conditions processed in the system. The study criteria for the first analysis included only those 

certificates that had at least one of the CACI pathologies and where the AME issued a non-time limited 

certificate. Criteria for the second analysis included certificates that only had one condition assigned to it, and 

that condition was a CACI. Certificates were individually examined to determine whether AMEs utilized the 

CACI process appropriately.

Results: The percentage of CACI certificates AMEs issued correctly increased slightly from 85% in 2013 to 

91% in 2014. The percentage of certificates that also contained the proper CACI documentation improved from 

19% in 2013 to 47% in 2014. When the certificates were categorized by each specific condition, the results of 

most categories improved between the two years. For the second analysis where CACI was assessed in the most 

ideal setting, the percentage of certificates where the AMEs issued correctly and wrote proper CACI 

documentation in the comments increased from 17% in 2013 to 51% in 2014. AMEs mismanaged 39% of the 

certificates in 2013 compared to only 9% in 2014.

Discussion: The results of our study indicate AMEs are applying the CACI criteria without decreasing pilot 

safety. There was a substantial improvement in AME compliance over the two-year study. However, the study 

identified opportunities for continuing AME education aimed at what is required to issue appropriately for 

specific medical conditions. As more conditions are added to the CACI protocol list, systematic safety and 

quality assurances need to be implemented.

17. Key Words

Medical Certification, Safety Assurance, CACI, Aviation, 

Medical Examiners

18. Distribution Statement

Document is available to the public

through the Internet: 

www.faa.gov/go/oamtechreports

19. Security Classif. (of this report)

Unclassified

20. Security Classif. (of this page)

Unclassified

21. No. of Pages

13

22. Price

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

iii

ACKNOWLEDGMENTS

We acknowledge and thank many people in the Aerospace Medical Ccertification Division. First, we thank Dr. 

Raad Abbas, the AAM-300 Quality Assurance physician who reviewed a sample of our study’s certificates to ensure 

we correctly categorized the exams in our analysis. Also, David Nelms provided data so we could determine the 

prevalence of deferred exams in the system. Others in AAM-300 who answered our questions through this process 

included Rita Wiley, Mitch Selensky, Dr. Judith Frasier, and Dr. Brian Johnson. We also thank Christy Hileman in 

AAM-600, who patiently and expertly provided the MANTRA data we requested for this analysis. 

v

Contents

Assessing the Effectiveness of the Conditions AMEs Can Issue Program: 2

Introduction. 

Background. 

Methods. 

Analysis 1. 

Analysis 2. 

Results- Analysis 1. 

2013. 

2014. 

Closer Comparison of 2013 and 2014. 

Results- Analysis 2. 

2013. 

2014. 

Discussion. 

Analysis 1. 

Analysis 2. 

Updates to the CACI Process. 

Recommendations. 

References. 

1

Assessing the Effectiveness of the Conditio

AMEs Can Issue Program: 201

INTRODUCTION

This paper describes the results from a two-year review of 

the CACI monitoring safety assurance process. When an aviation medical examiner (AME) examines an airman during the 

medical certification process, there are conditions for which an 

AME must defer to the Federal Aviation Administration before 

the airman’s certificate is issued. In 2013, the Office of Aerospace Medicine (OAM) implemented changes for nine specific 

conditions that would allow AMEs to process more applicants 

immediately following the examination. This process became 

known as Conditions AMEs Can Issue (CACI). OAM determined the nine conditions posed low safety risk in certification. 

However, a safety assurance review was needed to document the 

certification changes over time. 

Background

A top priority of the current Federal Air Surgeon is to increase the number of airmen that leave their AME’s office with 

a valid medical certificate the day of their exam and decrease the 

number of certificates AMEs must defer (Fraser, 2014). Due to 

constrained resources, application software changes, and staff 

attrition in the Aerospace Medical Certification Division, the 

number of days it took to process an airman application that 

was initially deferred increased from 2012 to 2013. To combat 

these issues, the Medical Certification Division collaborated with 

the OAM Safety Risk Management (SRM) team to determine 

specific medical conditions that represented controlled risk of 

flight safety, due to the extremely low likelihood of an accident, 

but potentially high severity of impact from mismanagement of 

the conditions. OAM identified nine medical conditions that 

posed low safety risk in certification, but all required an airman 

who possessed one of these conditions to obtain a special issuance 

medical certificate at that time. These conditions later became 

known as the original CACI conditions.

To estimate the effect the CACI process would have on the 

current airmen application workflow, the SRM team categorized 

all active airmen currently in the AMCD system based on whether 

they possessed one or more of the nine identified conditions. 

The results indicated 20 percent of active airmen possessed at 

least one of the proposed CACI conditions. Moreover, based on 

a range of assumptions about additional pathology an airman 

could possess in addition to the CACI conditions, we estimated 

the future impact in the Document Imagining Workflow System 

(DIWS) to range from a 6-17 percent decrease in workflow after 

the successful implementation of the CACI process (Johnson 

et al., 2012). Therefore, the CACI process would reduce the 

resources needed by the FAA to assess condition status and 

process certifications for seemingly low-risk conditions and allow 

those resources to shift to processing applications representing 

greater risk. 

OAM also sought to determine a potential association of CACI 

medical conditions and having a fatal aviation accident. Based on 

data from OAM’s Medical Analysis Tracking Registry-Autopsy 

Program Team (MANTRA), of 931 cases, 92 cases involved 

pilots that possessed one of the proposed CACI conditions in 

a fatal accident. The SRM team cross-referenced these 92 cases 

with their National Transportation Safety Board (NTSB) factual 

reports, and none of the medical conditions were documented as 

being causative or a factor leading to the accident. Thus, OAM 

concluded that the CACI process would allow AMEs to use 

their medical expertise to more efficiently issue an unrestricted 

certificate to those airmen with stable medical conditions that 

did not pose a significant medical risk for flight safety.

To meet the CACI requirements, a new policy was implemented for the process, in which AMEs must document and 

notate specific requirements on CACI worksheets for each of 

the nine conditions during an examination. In each instance, 

the AME must determine if 1) the airman “meets certification 

criteria” for the specific condition, 2) the “airman had a previous 

Special Issuance for this condition and now meets the regular 

issuance certification criteria,” or 3) the “airman does NOT 

meet certification criteria” for the specific condition and must 

be deferred to OAM for further examination (FAA, 2014). 

OAM determined the nine conditions posed low safety risk 

in certification, as long as AMEs were issuing these certificates 

appropriately. However, a safety assurance review was needed to 

document the certification changes over time. In June 2014, we 

completed our initial analysis of the 2013 CACI implementation, highlighting the need for more education and promotion 

of CACI procedures and documentation requirements among 

AMEs. Responding to the results, the Federal Air Surgeon 

published additional AME guidance for the CACI protocol in 

his editorial in the August 2014 Federal Air Surgeon’s Medical 

Bulletin (Fraser, 2014). We concluded that a follow-up analysis 

should be conducted for 2014 CACI data to determine how 

well AMEs complied with guidance published in the Medical 

Bulletin and to the additional online resources OAM’s Aerospace 

Medicine Education Division (AMED) provided. 

The goal of this two-year study was to describe the results 

from the CACI monitoring safety assurance process. This study 

focused on two aspects of the CACI process. In the first analysis, 

we assessed whether CACI reduced the safety of AME certificate 

issuance. In the second analysis, we took a different approach, by 

using the simplest form of CACI cases described in the Methods 

section to determine the overall AME compliance rate for the 

process each year.
2

METHODS

The SRM team analyzed three months of medical certification data from 2013 to determine the number of CACI-related 

conditions processed in the system during the last quarter of 

the fiscal year. We identified separate study samples for the two 

analyses. It was not feasible to review the thousands of CACI 

certificates OAM received each month, so a representative sample 

of certificates were individually examined and categorized based 

on correct issuance and documentation. Cases were selected for 

the sample if they contained any changes in administrative or 

medical pathologies in their certificate during this time period. 

Analysis 1

For the first analysis, the study criteria represented only those 

certificates that had at least one of the CACI medical pathologies (pathcodes) and where the AME issued a certificate that 

was not time-limited, meaning the certificate was valid for the 

entire period of a normal certificate, without having to meet 

other medical guidelines in between recertification periods. We 

repeated the analysis for the same three months of 2014 CACI 

data to compare with the 2013 analysis.

The analyses were performed on certificates that had at least 

one of the original nine CACI conditions: 1) Arthritis, 2) Asthma, 

3) Glaucoma, 4) Hepatitis C, 5) Hypertension, 6) Hypothyroidism, 7) Migraine, 8) Pre-Diabetes, and 9) Renal Cancer. The 

colitis condition was added in 2014 and was therefore included 

in the three-month 2014 analysis as the tenth CACI condition. 

The certificates were separated into four categories in the 

analyses: 1) Appropriate Issuance, where an AME issued a nontime-limited certificate with proper CACI worksheet documentation in the notes; 2) Incomplete Error, where the AME issued 

a non-time-limited certificate but failed to appropriately cite 

proper CACI documentation in their notes; 3) Inappropriate 

Error, where an AME failed to provide proper documentation 

to determine the airman’s non-time-limited status; and 4) Inappropriate Error where the certificate was reversed when OAM 

determined a special issuance or denial was needed after the AME 

had already issued a non-time-limited certificate. We measured 

these four categories using the overall number of certificates, 

and then examined the improvement between 2013 and 2014 

by comparing each individual CACI condition.

Analysis 2

For the second question in the study, the SRM team added 

another analysis to obtain a group of certificates with the simplest medical histories possible. We assumed that where cases 

are simple, involving a single medical pathology, they are most 

likely to be acceptable under CACI guidance, giving the best 

scenario for the use of the policy. We used the same three months 

of 2013 data included in the first analysis. From this group, we 

obtained and individually reviewed a sample of those certificates 

that only had one pathcode assigned to it, and that pathcode 

was a CACI condition. We repeated the process for the three 

months of 2014 data.

These certificates were categorized according to deferral, 

non-time-limited issuance, and time-limited certificate issuance 

status. The seven categories were 1) Appropriate Deferral, where 

the AME deferred because the airman’s condition was not CACI 

eligible at the time of the exam, 2) Inappropriate Deferral, where 

the AME deferred even though the airman was actually CACIeligible, 3) Appropriate Non-Time-Limited Issuance, where an 

AME issued a non-time-limited certificate with proper CACI 

worksheet documentation in the notes, 4) Incomplete Issuance, 

where the AME issued a non-time-limited certificate but failed 

to appropriately cite proper CACI documentation in the notes, 

5) Inappropriate Issuance, where an AME inappropriately issued 

a non-time-limited certificate without initial sufficient evidence 

or failed to provide all documentation, 6) Appropriate TimeLimited Issuance, where the applicant was appropriately issued 

a time-limited certificate because the airman’s certificate was not 

CACI-eligible, and 7) Inappropriate Time-Limited Issuance, 

where the AME issued a time-limited certificate when the airman’s certificate should have been CACI-eligible. 

RESULTS- ANALYSIS 1

2013

Results from the first analysis evaluated whether CACI was 

appropriately applied and documented when the AMEs issued 

non-time-limited certificates, and are shown in Table 1. Overall, 

493 cases were reviewed, with 418 certificates fitting into one of 

the four categories. Seventy-five certificates of the original 493 

were taken out of the total because they were not CACI-related 

(i.e., historical pathcodes or pathcodes that were not related to 

the nine original CACI conditions). 

In 85% of the certificates, AMEs issued certificates correctly. 

However, only 19% of certificates properly noted CACI protocol, 

as required by the CACI procedure. About 15% of certificates 

were either issued incorrectly or without proper documentation 

of proof to issue. During these three months, there was only 

a minor improvement in these incorrectly issued certificates 

(17.1% to 14.4% to 13.6%).
3

2014

Overall, we reviewed 692 cases, with 626 certificates fitting 

into one of the four categories in Table 2. Sixty-five certificates 

of the original 692 were taken out of the total because they were 

not CACI- related. One certificate was removed because it was 

still in the workflow queue.

Over 91% of the certificates were issued correctly. More than 

half (51%) of these certificates properly noted CACI protocol 

where indicated. About 9% of certificates were either issued 

incorrectly or without proper documentation of proof to issue. 

During these three months, there was a substantial improvement 

in these incorrectly issued certificates (14.9% to 10.2% to 5.3%).

Table 1: Three-Month Summary of AME Actions for 2013 CACI Certificates

Month

Outcome

(%) Total

Incorrect Issuance Correct Issuance

Appropriately 

Issued and 

Documented

Incomplete 

Error- Failed 

to cite CACI

Inappropriately 

Issued- Insufficient 

Evidence

OAM Certificate 

Reversal/Change 

to SI

Jul. 30

(17.8)

110

(65.1)

21

(12.4)

8

(4.7) 169

Aug. 20

(15.2)

93

(70.5)

15

(11.4)

4

(3.0) 132

Sep. 29

(24.8)

72

(61.5)

8

(6.8)

8

(6.8) 117

Total 79

(18.9)

275

(65.8)

44

(10.5)

20

(4.8) 418

Table 2: Three -Month Summary of AME Actions for 2014 CACI Certificates

Month

Outcome

(%) Total

Incorrect Issuance Correct Issuance

Appropriately 

Issued and 

Documented

Incomplete ErrorFailed to cite 

CACI

Inappropriately 

Issued- Insufficient 

Evidence

OAM Certificate 

Reversal/Change 

to SI

Jul. 39

(44.8)

35

(40.2)

9

(10.3)

4

(4.6) 87

Aug. 112

(43.9)

117

(45.9)

19

(7.5)

7

(2.7) 255

Sep. 140

(49.3)

129

(45.4)

12

(4.2)

3

(1.1) 284

Total 291

(46.5)

281

(44.9)

40

(6.4)

14

(2.2) 626
4

Closer Comparison of 2013 and 2014

After we examined the overall results, we also wanted to 

determine if the AMEs demonstrated improvement, based on 

each type of CACI medical condition the AMEs were presented 

with at the time of the exams. The results are presented in Table 

3. Overall, 493 CACI pathcodes from the 418 certificates were 

included in the analysis that contributed to the AMEs’ issuance 

decisions in 2013. We compared those to the 651 significant 

CACI pathcodes from the 626 certificates in 2014.

Arthritis

The percentage of incorrect issuances for certificates with the 

arthritis codes increased between 2013 and 2014. This indicated 

AMEs still needed education on properly citing the CACI protocol for this condition.

Asthma

AMEs slightly improved the percentage of correct issuances 

from 2013 to 2014. AMEs needed further education in what was 

required to issue without a special issuance, as indicated by the 

22% and 16% incorrect issuance in 2013 and 2014, respectively. 

Glaucoma

AMEs improved in appropriately issuing and documenting 

certificates with the glaucoma pathcode between the two years 

(10% vs. 46%). However, even in 2014, more than 25% of these 

certificates were issued incorrectly.

Hepatitis C

There was nothing substantial to examine since there were 

very few certificates in each year with hepatitis C from the 

analysis. The lack of certificates with hepatitis C in the study 

could mean that many AMEs did not understand they could 

issue without a special issuance for this condition, or they were 

not as comfortable doing it.

Hypertension

The majority of certificates included in this study contained 

either hypertension or hypothyroidism pathcodes. There was 

an improvement in AMEs appropriately issuing between the 

two years (22% compared to 54%). In addition, only 3% of 

the hypertension certificates were incorrectly issued in 2014 

compared to 8% in 2013.

Table 3: Comparison of AME performance by CACI Condition for 2013 and 2014

CACI 

Pathcode

Outcome (%)

Total

Correct Issuance Incorrect Issuance

Appropriately 

Issued and 

Documented

Incomplete ErrorFailed to cite 

CACI

Inappropriately 

Issued- Insufficient 

Evidence

OAM Certificate 

Reversal/Change 

to SI

Arthritis

2013 2 (5) 42 (93) 1 (2) 0 (0) 45

2014 1 (5) 13 (62) 5 (24) 2 (9) 21

Asthma

2013 7 (13) 35 (65) 11 (20) 1 (2) 54

2014 18 (25) 42 (59) 7 (10) 4 (6) 71

Glaucoma

2013 2 (10) 10 (53) 3 (16) 4 (21) 19

2014 5 (46) 3 (27) 2 (18) 1 (9) 11

Hepatitis 

C

2013 1 (50) 1 (50) 0 (0) 0 (0) 2

2014 1 (100) 0 (0) 0 (0) 0 (0) 1

Hypertension

2013 59 (22) 193 (70) 12 (4) 11 (4) 275

2014 231 (54) 182 (43) 11 (3) 2 (0) 426

Hypothyroidism

2013 10 (15) 39 (60) 15 (23) 1 (2) 65

2014 41 (53) 27 (35) 9 (11) 1 (1) 78

Migraine

2013 5 (31) 6 (37) 3 (19) 2 (13) 16

2014 4 (22) 12 (67) 2 (11) 0 (0) 18

PreDiabetes

2013 1 (12) 5 (63) 0 (0) 2 (25) 8

2014 3 (37) 2 (25) 1 (13) 2 (25) 8

Renal

Cancer

2013 2 (22) 5 (56) 1 (11) 1 (11) 9

2014 0 (0) 1 (50) 0 (0) 1 (50) 2

Colitis

2013 N/A N/A N/A N/A N/A

2014 2 (13) 7 (47) 5 (33) 1 (7) 15
5

Hypothyroidism

Results for hypothyroidism were similar to hypertension. 

AMEs improved in appropriately issuing the certificates (15% 

in 2013 compared to 53% in 2014). The percentage of incorrect 

issuances decreased from 25% in 2013 to 12% in 2014. 

Migraines

There were fewer appropriate documentation and issuances 

for certificates with the migraine pathcode in 2014 compared 

to 2013 (22% vs. 31%). However, the number of incorrect issuances with the migraine pathcode decreased 3-fold between 

the two years (32% vs. 11%). 

Pre-Diabetes

Similar to the results of the arthritis pathcode certificates, 

AMEs increased the number of incorrect issuances for certificates 

with the pre-diabetes codes between 2013 and 2014. There were 

more appropriate issuances in 2014, but the cases for both years 

were very small for this pathcode, so it was difficult to ascertain 

if AMEs understood the CACI process for this condition.

Renal Cancer

This condition was also difficult to compare because there were 

only two certificates in 2014 with renal cancer pathcodes in the 

analysis. Again, this might have been because AMEs were unsure 

if they could issue without a special issuance using CACI criteria.

Colitis

The colitis pathcode was only included in the 2014 analysis, 

but it gave a suitable comparison to the other 2013 conditions 

since OAM recently introduced the colitis CACI worksheet in 

April 2014. The exams with this pathcode had the most incorrect issuances (40%) of all the individual pathcodes, and AMEs 

appropriately issued only 13% of the time.

RESULTS- ANALYSIS 2

2013

For the second analysis, we wanted to determine how well 

AMEs utilized the new CACI process in its most ideal form. 

Using the same three months as in the first analysis, we obtained 

a sample of those certificates that only had one pathcode assigned 

to them, and that pathcode was a CACI condition. This identified 93 certificates to individually review. Two were removed 

because they were still in the workflow queue, and six additional 

certificates were removed because the conditions were not CACIrelated conditions. The remaining 85 certificates fit into seven 

categories outlined below, along with a table to breakdown the 

categories by month.

As displayed in the table, 38% of the time AMEs appropriately deferred, meaning the certificates were not CACI eligible 

or the airman did not have complete paperwork at the time of 

his exam. Thirteen percent inappropriately deferred when the 

airman’s certificate was actually CACI-eligible. Nine percent of the 

AMEs appropriately issued certificates to the airmen by writing 

proper CACI worksheet documentation on their examination 

information. Twenty-three percent of AMEs performed an incomplete issuance error because they failed to write “CACI” in 

comments in the examination notes. Finally, 3.5% of the time 

AMEs inappropriately issued a non-time-limited certificate 

without initial sufficient evidence pertaining to the condition or 

failing to provide all the required documentation to OAM at the 

time. AMEs appropriately issued a time-limited certificate 4.7% 

of the time due to the condition not being CACI-eligible. Eight 

percent of the time AMEs inappropriately issued a time-limited 

exam when it could have been issued based on the CACI criteria. 

The highlighted table columns in Table 4 represent the total 

number of exams where the CACI process could have been 

utilized. Summing these 4 columns and examining the criteria, 

the SRM team calculated 46 out of the 85 certificates were 

CACI-eligible (54%). AMEs mismanaged 18 of these 46 cases 

(39%) due to either inappropriately deferring or inappropriately 

Table 4: 2013 Exams Containing Only One Pathcode

Month Outcome

(%) Total

Defer Issue Non-Time Limited Issue Time Limited

Appropriate Inappropriate Appropriate 

w/Comments

Incomplete 

Error Inappropriate Appropriate Inappropriate

Jul. 8

(23.5)

6

(17.6)

7

(20.6)

7

(20.6)

0

(0.0)

3

(8.8)

3

(8.8) 34

Aug. 17

(48.6)

3

(8.6)

1

(2.9)

9

(25.7)

1

(2.9)

1

(2.9)

3

(8.6) 35

Sep. 7

(43.8)

2

(12.5)

0

(0.0)

4

(25.0)

2

(12.5)

0

(0.0)

1

(6.25) 16

Total 32

(37.6)

11

(12.9)

8

(9.4)

20

(23.5)

3

(3.5)

4

(4.7)

7

(8.2) 85
6

issuing a time-limited certificate when it could have been issued 

based on the CACI criteria. There were only eight (17.4%) 

of the 45 instances where AMEs actually wrote proper CACI 

documentation in the comments, which is similar to the 19% 

of certificates that had appropriate CACI documentation in the 

2013 first analysis. 

2014

The SRM group repeated the second analysis for the same 

three months in 2014 as used in 2013. From this group, we obtained a sample of those certificates that only had one pathcode 

assigned to them, and that pathcode was a CACI condition. This 

identified 311 certificates, which we individually reviewed. One 

certificate was taken out of the total because it was still in the 

workflow queue, and 18 additional certificates were taken out 

because the conditions were not CACI-related conditions. The 

remaining 292 certificates fit into the seven categories.

Based on Table 5, in general, there were a smaller proportion 

of certificates that needed to be deferred in 2014 compared to 

2013. This indicated the CACI process helped more of these 

airmen obtain a non-time-limited certificate quickly. Seventythree percent of the time AMEs utilized the appropriate CACI 

process to issue a non-time limited certificate. The highlighted 

table columns represent the total number of certificates where 

the CACI process could have been utilized. Summing these 

four columns, we calculated that 236 of the 292 certificates 

were CACI-eligible (81%). Table 6 demonstrates there was 

substantial improvement from 2013 to 2014, based on the 

results of Analysis 2. 

DISCUSSION

Analysis 1

The results indicate AMEs substantially improved compliance with CACI protocol over the two-year study period. At 

the conclusion of the study, more than 91% of AMEs correctly 

issued CACI certificates. The percentage of correctly issued 

certificates that also appropriately documented CACI criteria 

improved from 22.3% in 2013 to 50.9% in 2014. The percentage of inappropriate issuances declined not only from 2013 to 

2014, but also declined throughout the 3-month period in 2014 

(decreased to 5.3% in September 2014). 

When categorizing certificates by specific conditions, the SRM 

team discovered most of the categories contained opportunities 

for continuing AME education aimed at what is required to issue 

appropriately for specific pathcodes such as asthma, arthritis, 

glaucoma, and migraine conditions. The lack of certificates from 

certain pathcodes in the analyses may indicate AMEs still do not 

understand they can issue without a special issuance limitation 

in these instances. Examining the colitis pathcode categorization 

Table 5: 2014 Exams Containing Only One Pathcode

Month Outcome

(%) Total

Defer Issue Non-Time Limited Issue Time Limited

Appropriate Inappropriate Appropriate 

w/Comments

Incomplete 

Error Inappropriate Appropriate Inappropriate

Jul. 19

(38.8)

6

(12.2)

12

(24.5)

7

(14.3)

3

(6.1)

0

(0.0)

2

(4.1) 49

Aug. 6

(5.7)

5

(4.7)

46

(43.4)

37

(34.9)

7

(6.6)

1

(1.0)

4

(3.8) 106

Sep. 9

(6.6)

3

(2.2)

62

(45.3)

50

(36.5)

6

(4.4)

5

(3.6)

2

(1.5) 137

Total 34

(11.6)

14

(4.8)

120

(41.1)

94

(32.2)

16

(5.5)

6

(2.1)

8

(2.7) 292

Table 6: Two-Year Comparison of CACI-Eligible Certificates

Comparison Category 2013 2014

• Percent certificates that were CACI eligible 54% 81%

• Percent certificates where CACI was not utilized correctly 39% 9%

• Percent certificates where AMEs wrote proper CACI 

documentation in comments 17% 51%
7

provided a comparison with other conditions in 2014 that were 

implemented the previous year. The colitis certificates contained 

the highest inappropriate issuance percentage (40%), which indicates that AMEs require more than a year to fully understand 

the new OAM issuance requirements. 

OAM’s AME Quality Assurance (QA) physician provides 

oversight of the AMEs by reviewing a random selection of certificates on a semi-annual basis to determine how well the AMEs 

certified the airmen. Our results were consistent with the QA 

physician’s findings of 9-10% error rates of AME performance 

in 2013 and 2014. The QA physician attributed more than 90% 

of identified errors to the CACI program (Abbas, 2014). The rise 

in the overall number of CACI certificates identified in August 

and September of 2014 was likely attributed to the Federal Air 

Surgeon’s Medical Bulletin article that reminded AMEs of appropriate CACI protocol (Fraser, 2014). The significant decrease 

of inappropriate issuances during the three-month period may 

have also been a direct benefit from that article. Finally, this 

analysis identified a need for continual AME education regarding CACI procedures and documentation. 

Analysis 2

To answer the second question posed, we added another 

analysis to obtain a group of certificates with the simplest medical 

histories as possible. We analyzed how CACI was being utilized 

by AMEs in its simplest form, or the efficiency that would be 

gained from the CACI process if AMEs only had to worry about 

the one applicant pathology to certificate. We discovered missed 

opportunities where AMEs did not fully utilize the CACI process. 

However, the percentage where AMEs could have issued without 

a time-limited restriction, but did not, decreased from 40% in 

2013 to 9.3% in 2014. The vast improvement in all areas of 

AME appropriate documentation and issuance signified general 

increased awareness and education of CACI criteria for 2014. 

This was also consistent with OAM’s estimation of a two-year 

period for AMEs to fully understand and comply with most 

major rule changes. 

Previous research confirmed there was very little risk associated with certifying certificates with CACI conditions if the 

conditions meet the specified criteria (Johnson et al., 2012). 

The results of this study indicate that AMEs applied the CACI 

criteria without increasing safety concerns of AME certificate 

issuance. To compare the pre-CACI implementation research 

using the OAM’s Autopsy MANTRA database, we reexamined 

the data post-CACI implementation. There were eight fatal 

cases documented where the pilot-in-command had at least one 

CACI condition recorded on his certificate from an exam on or 

after April 2013, the date when CACI was implemented. After 

cross-referencing these cases with the NTSB factual reports, 

none of the causes or factors in the accidents was due to medical 

conditions. Therefore, the CACI process has not increased the 

medical risk for flight safety. 

Updates to the CACI Process

From the time this two-year study concluded, the AMCD 

made updates to the CACI process to improve the expectations of 

the CACI process during the medical certification examinations. 

They updated the CACI worksheets in the Guide to Aviation 

Medical Examiners with simplified wording for the AME to use 

in the comments section. This increased compliance by AMEs 

that did not write the previous lengthy statements about CACI 

qualifications. To increase airmen compliance, the AMCD started 

sending informational letters to the airmen who renew their 

medical certificates if they possess a qualified CACI condition. 

This letter explains the CACI process, why the airmen are no 

longer required to obtain a special issuance, a list of steps for the 

airmen to comply with before their next exam, and where they 

can access online materials. Moreover, OAM recently released 

CACI worksheets for prostate and testicular cancer to make 

them consistent with the other CACI condition procedures. 

Additionally, they have released worksheets on three new CACI 

conditions, bladder cancer, kidney stones, and chronic kidney 

disease to increase the number of medical certification applicants 

that no longer require a special issuance (FAA, 2015). 

One of the Federal Air Surgeon’s objectives is to increase the 

percentage of airmen that can obtain a medical certificate the 

same day the AME performs the medical examination. The 

purpose of the CACI process is to allow more airmen to obtain 

a non-special issuance exam without going through the deferral 

process. Over the last four years, there has been a 20% reduction 

in the percentage of deferred medical certificates, decreasing from 

approximately 5% to slightly less than 4%. On the other hand, 

the percentage of special issuances has stayed relatively the same 

since CACI has been implemented, at approximately 6.5% of 

all active airmen in the system. However, OAM expects fewer 

special issuances in the near future. Because the CACI process 

has only been implemented for a few years, many of the pilots 

in the system have not yet renewed their certificates since OAM 

made the new changes to CACI. In a few years, more airmen 

will go through the renewal process, and OAM expects to see 

an even greater reduction of special issuances in the system. 

RECOMMENDATIONS

Due to limited resources, studies conducted on specific AME 

protocol are often not feasible. The Medical Certification division 

has recently made several improvements to the CACI process. 

However, to increase AME compliance with the CACI process, 

OAM should create auto-populated CACI phrases for AMEs 

in their comments section of the airman’s medical certificate. 

Additionally, to improve internal auditing of the system, they 

should start systematically flagging the CACI certificates routed 

to the AMCS for routine safety and quality assurance. Based 

on these results, OAM would benefit from continual AME 

education aimed at what is required to issue appropriately 
8

for specific CACI pathcodes that have been more difficult for 

AMEs to comply with, such as asthma, arthritis, glaucoma, and 

migraine conditions. Future safety assessments will be required 

to determine how AMEs and airmen are complying with the 

newly implemented CACI condition protocol. 

REFERENCES

Abbas R. AAM-300 Quality Assurance (QA) Program. JanuaryJune 2014 Internal OAM Report. Oklahoma City, OK. 

Dec 2014.

FAA. (2014). Guide for Aviation Medical Examiners- CACI 

Conditions. Federal Aviation Administration Office of 

Aerospace Medicine. Retrieved December 2014 from: 

http://www.faa.gov/about/office_org/headquarters_

offices/avs/offices/aam/ame/guide/certification_ws/

FAA. (2015). Guide for Aviation Medical Examiners- CACI 

Conditions. Federal Aviation Administration Office of 

Aerospace Medicine. Retrieved September 2015 from: 

http://www.faa.gov/about/office_org/headquarters_

offices/avs/offices/aam/ame/guide/certification_ws/

Fraser JR. From the Federal Air Surgeon: CACI Update. The 

Federal Air Surgeon’s Medical Bulletin 2014. 52(3): p. 2-3. 

Johnson BD, Frazier J, Selensky M. CACI ProgramConditions AMEs Can Issue. Presented at the 2012 

FASMT meeting, Oklahoma City, OK. Nov 2012.