According to FAA, safety is the FAA’s most important mission and its goal is to achieve the lowest possible accident rate and constantly improve safety. Supporting this safety goal are a number of activities and requirements including federal regulations that require pilots to have both a pilot certificate and medical certificate prior to operating an aircraft and meet several requirements, depending on the level of certificate FAA issues the applicant. In order for FAA to issue a pilot certificate, applicants must demonstrate various piloting skills; pass written tests of aeronautical knowledge; log specified hours of flying time; read, speak, write, and understand the English language; and meet certain age restrictions, in addition to meeting the physical qualifications for a medical certificate and undergoing certain background checks. FAA authorizes pilots to fly specific types of airplanes or use specific types of aeronautical instruments after they meet certain training and testing requirements. Federal regulations establish three classes of medical certification that correspond to the duties that pilots perform. Airline transport pilots that serve as pilots in command of scheduled air carrier operations must hold first-class medical certificates. Pilots that fly for compensation or hire or serve as flight engineers or flight navigators, as well as air traffic control tower operators, generally hold second-class medical certificates. Private pilots hold third-class medical certificates. Pilots must undergo medical examinations periodically to renew medical certificates (see table 1). A pilot begins the medical certification process by completing an application, including reporting his or her medical history on the application, certifying that it is complete and true, and authorizing the National Driver Register, through a designated state department of motor vehicles, to furnish to the FAA information pertaining to his or her driving record. A pilot applicant is examined by an aviation medical examiner (AME), who is a qualified physician in private practice in whom FAA has delegated the authority to examine pilot applicants and make certification decisions on behalf of FAA. To become an AME, FAA requires physicians to receive basic training at its Civil Aerospace Medical Institute and recurrent training through seminars to stay abreast of any changing medical science. FAA collects information through a database to monitor and evaluate the performance of AMEs. For example, if an AME makes an error, FAA describes the type of error that was made in its database. Finally, FAA has the authority to supersede and modify an AME’s decision to issue or deny a medical certificate. FAA has established medical certification procedures to identify whether pilots meet medical standards. As part of these procedures, AMEs decide whether or not to issue pilot medical certificates based on information gathered from pilots and their physical examinations. In the majority of cases, pilots meet the medical standards for certification and AMEs issue the medical certificate. In addition to the AME examination, FAA has a computer system that initially processes all the applications and prioritizes some for review, such as those where the AMEs deferred the decision or denied the certificate. The computer system also identifies for further review applications where the AME has issued the medical certificate and the application indicates potentially disqualifying medical conditions. Finally, FAA checks the National Driver Register to help ensure pilots meet standards by checking for indications of substance abuse. AMEs determine whether a pilot meets FAA medical standards based on their review of the pilot’s medical certification application and the results of their physical examination. Pilots are responsible for providing information on the application describing their medical history to alert the AME of any health-related condition, such as cardiac problems or mental disorders. Pilots also report whether their FAA medical certificate has ever been denied, suspended, or revoked. In addition to answering medical questions, the application requires the pilot to report any convictions and administrative actions (e.g., suspensions or revocations) involving driving while intoxicated, impaired, or under the influence of alcohol or drugs. The AME is responsible for reviewing the applicant’s responses on the application form to identify inconsistencies, missing information, and disqualifying conditions. The AMEs next conduct a physical examination. In 2007, FAA had about 4,400 AMEs conducting physical exams. To verify pilot information and identify potential medical issues, the AME examines the pilot for vision, hearing, mental, neurological, cardiovascular, and general medical conditions. Additionally, if the pilot is applying for a first-class medical certificate, the AME must conduct an electrocardiogram annually for pilots over the age of 40. During the course of the medical examination, the AME should use the information obtained from the review to ask the applicant pertinent questions, especially questions that deal with type of medications and pilot’s medical history. For example, if the applicant reported use of anticoagulants or indicated that he or she had a coronary artery angioplasty procedure, then the AME would be prompted to ask the applicant to provide a copy of any FAA correspondence that authorized medical certification on the medication or following the procedure; or request the applicant to provide medical documentation regarding these treatments and conditions. Certain aspects of the applicant’s medical history may require more information. For example, if the pilot answered yes to having experienced heart or vascular trouble on his or her application, the AME is required to ask the pilot to clarify the significance of that item of history by asking for supplementary reports from the applicant’s personal physician. After reviewing the medical history and completing the medical examination, AMEs make one of the following determinations: issue a medical certificate, issue a special certificate, defer making a decision, or deny the certificate. The AME may issue a medical certificate when the applicant meets all medical standards. In such cases, the pilot leaves the AME’s office with his or her medical certificate in hand. AMEs may also issue a special, time-limited medical certificate (or special issuance) to pilots whose medical conditions do not meet the federal medical standards but have received FAA authorization to obtain a medical certificate because they can perform their duties without endangering public safety. FAA may require pilots to take a special medical flight test, practical test, or medical evaluation for this purpose. The AME may defer the application for FAA review when the applicant exhibits one or more disqualifying medical conditions. (See app. III for a list of disqualifying medical conditions.) The AME may deny certification when the applicant does not meet the medical standards. When the AME defers or denies the application for a medical certificate or issues a certificate under an authorization for special issuance, the application is routed to FAA application examiners who decide whether to issue or deny the certificate. FAA established a computer system that prioritizes application review procedures in order to target its resources toward applications that it determined needed the most review. FAA’s computer system, called Document Imaging Workflow System (DIWS), initially processes all medical certification applications and designates each one as either a priority or a non-priority application. See table 2 for definition of priority and non-priority applications. In 2007, of the 438,152 medical certification applications received, DIWS designated 34,590 applications as priority applications, 399,962 applications as non-priority, and 3,600 as in process. FAA’s computer system identifies and closes most non-priority applications. In 2007, for example, FAA automatically processed and closed the applications where AMEs issued medical certificates—about 88 percent of all medical applications. After AMEs submit the applications, DIWS routes priority applications to application examiners for review. These examiners review the medical certification applications, supporting documentation, and any previous medical issues in a pilot’s medical file. They follow FAA regulations, guidance, and consult with FAA physicians in order to decide whether to issue or deny the certificate. In 2007, FAA application examiners evaluated all 34,590 priority applications (see fig. 2). In 2006, as a result of growing concern by pilots and FAA’s management about the length of time to review priority applications, FAA established a goal of completing each application review in 30 days. According to FAA, as of February 2008, the average time to process a priority application is 24 days. 0.82% In process(3,600) 71.2% (34,590) Priority applications (deferred, denied, and special issuances) 28.8% (13,967) Non-priority applications with potentially disqualifying medical conditions (48,557) FAA’s computer system also evaluates non-priority applications (applications where the AME decided to issue a certificate) and identifies ones where the pilot or AME indicated one or more potentially disqualifying medical conditions on the application. FAA programmed DIWS to route these applications to application examiners for review due to the presence of a potentially disqualifying medical condition. For example, in 2007, of the applications that were designated as non-priority applications, DIWS identified 13,967 with one or more potentially disqualifying medical condition such as a history of heart or vascular trouble, diabetes, or epilepsy. However, according to FAA officials, FAA’s application examiners rarely if ever review these applications due to workload and time constraints and these applications are removed from the examiners’ workload after about two months. Once removed, non- priority applications are closed without being reviewed by an application examiner, thus making the AME’s decision to issue the medical certificate final. A random sample of closed non-priority applications are subsequently selected for quality assurance review. FAA officials indicated that one impact of not reviewing non-priority applications is a greater reliance on AMEs to make a correct determination and identify pilots that may have potentially disqualifying medical conditions. Because FAA application examiners rarely have time to review these non-priority applications, the burden is on the AME to make the correct determination. According to FAA, this makes the AMEs the first and sometimes the only line of defense because few if any non- priority applications are ever reviewed. More often than not, the AME decisions are considered final. Because of their importance, FAA trains AMEs to identify pilots that have potentially disqualifying medical conditions or may not be medically fit to fly.