According to FAA officials, FAA’s medical certification requirement was established to prevent or mitigate the effect of various medical conditions that present an undue risk to the safety of pilots, passengers, or others. While most general aviation accidents are attributed to pilot error involving a loss of aircraft control, according to information provided by NTSB, medical causes were a factor in approximately 2.5 percent of the accidents from 2008 through 2012. By ensuring that applicants meet medical standards, FAA aims to reduce the likelihood of incapacitation of a pilot due to a medical cause. Federal regulations establish three classes of medical certification that correspond to the types of operations that pilots perform. Airline transport pilots who serve as pilots in command of scheduled air-carrier operations must hold first-class medical certificates. Pilots who fly for compensation or hire generally hold second-class medical certificates. Private pilots hold third-class medical certificates. (See table 1.) Depending on their age and the class of medical certificate sought, pilots must renew their medical certificate periodically, from every 6 months to every 5 years (e.g., commercial pilots—generally those needing first- or second-class medical certificate—must have their medical certificate updated more frequently than private pilots). After obtaining a medical certificate, and between renewal periods, pilots are prohibited from performing pilot operations when they know or have reason to know of a medical deficiency that would make them unable to fulfill their pilot operation. In the fiscal year 2014 budget submission, FAA estimated that its Office of Aerospace Medicine would need about $56.1 million in funding—about 4.7 percent of the total Aviation Safety budget—to carry out its mission. To assist in the nearly 400,000 medical evaluations of pilots and new applicants each year, FAA designates medical certification authority to approximately 3,300 private physicians, or Aviation Medical Examiners (AMEs). The AMEs review applicants’ medical histories and perform physical examinations to ensure that applicants meet FAA’s medical standards and are medically fit to operate an aircraft at the time of their medical exam. Although AMEs are not FAA employees, they are trained in aviation medicine by the FAA and entrusted to make medical eligibility determinations for the majority of applicants, on behalf of the FAA. In order to become an AME and be authorized to administer medical exams, FAA requires AMEs to complete online courses in clinical aerospace physiology and medical certification standards and procedures before attending a one-week basic AME seminar. AMEs must also complete at least 10 pilot medical exams each year and a subsequent refresher courses every 3 years. All applicants for medical certificates and renewals follow a similar process. Applicants begin the medical certification process by completing Form 8500-8, Application for Airman Medical Certificate or Airman Medical & Student Pilot Certificate (medical application form) in MedXPress (online application system). For applicants with disqualifying medical conditions or for those who do not meet FAA’s medical standards, the AME must defer the applicant to FAA to authorize a special issuance. The special issuance process may require additional medical information and evaluations from, for example, a primary care physician or medical specialist. Also, a special issuance may be subject to operational limitations for safety reasons, or may be valid for a shorter time period than an unrestricted medical certificate. As a provision of the special issuance, FAA may authorize AMEs to make future medical determinations of the applicant—separate from the centralized special issuance process—under the AME Assisted Special Issuance (AASI) process. various outcomes. Alternatively, if FAA determines that an applicant’s medical condition is static and non- progressive and has found the applicant capable of performing pilot duties without endangering public safety, the FAA may grant a Statement of Demonstrated Ability (SODA) to the applicant, which does not expire and authorizes AMEs to make future medical determinations of the applicant, without requiring the applicant to go through the special issuance review process. According to FAA officials, pilot medical standards were developed to help manage safety risk. FAA’s current medical standards have been codified in federal regulation since March 19, 1996. The regulations set out 15 medical conditions that are specifically disqualifying. Medical conditions identified during an evaluation that are not specifically listed as disqualifying but do not meet the general medical standard regarding safe performance of duties and exercise of privileges, are also disqualifying under general medical standards, according to FAA. (See app. II for a summary of selected FAA medical standards.) According to FAA officials, the standards and the medical certification process were developed to manage the risk of an aircraft accident or incident by identifying applicants with medical conditions that could potentially incapacitate them in the flight environment or during critical take-off and landing periods. FAA takes steps designed to ensure that its medical policies and procedures are consistent with current medical and aeromedical practice, and that these steps result in periodic updates to its medical policies. The Federal Air Surgeon establishes medical policies and medical certification procedures that are published in internal guidance for FAA’s Office of Aerospace Medicine and for AMEs in the Guide for Aviation Medical Examiners (AME Guide). The agency uses several techniques to update policies: First, the Aeromedical Standards and Policies Branch develops policy recommendations for the Federal Air Surgeon, which address medical conditions, medication use, and medical procedures. According to FAA officials, medical policy review is a continuous process influenced by several factors, which include (1) announcements of significant new developments in the medical literature; (2) medical appeals to the Federal Air Surgeon; (3) announcements and alerts by the Food and Drug Administration; (4) inquiries by aviation stakeholder groups and pilot advocacy groups; (5) aircraft accidents or events; (6) inquiries by the Office of Aerospace Medicine personnel and AMEs; and (7) communications with international aviation authorities, and medical advocacy groups, among other things. Second, according to FAA officials, the agency refers dozens of individual cases annually for independent review by experts in a wide variety of medical specialties, such as cardiology, psychology, and neuropsychology. FAA officials stated that implicit to the process of reviewing each case is to consider changes to current policy based on current medical practice. FAA also periodically uses independent medical experts to evaluate its medical policies, particularly with regard to cardiovascular conditions, which were present in more than one-third of the applicants who received special issuances in 2012. In January 2013, for example, FAA hosted a cardiology roundtable to review FAA’s policies with regard to cardiovascular conditions and to suggest updates to the policies, if necessary. The roundtable’s suggested policy changes were presented to the Federal Air Surgeon, who approved several of them. However, FAA officials have said that they do not convene such roundtables frequently due to time and cost constraints. Third, the results of CAMI’s aerospace medical and human factors research have been used to inform changes to FAA guidance and policies. In particular, CAMI’s aerospace medical research focuses on the biomedical aspects of flight, including studies on aviation safety associated with biomedical, pharmacological, and toxicological issues. For example, CAMI’s research on sedating medication influenced guidance in this area. According to FAA officials, a review of accident investigation data showed that many pilots involved in accidents were using over the counter and prescription sedative medications. As a result, FAA, in coordination with the aviation industry, issued guidance extending the length of time a pilot should wait after using these medications and before operating an aircraft. A letter jointly signed by the FAA and all major aviation advocacy groups was sent to all pilots and published on the FAA website and in various public and private publications advising pilots to comply with the new guidance. Fourth, CAMI’s library allows research staff to collect and review academic journals on aviation medical issues, general medical research, engineering, management, and other general topics. CAMI researchers have also published approximately 1200 aerospace medicine technical reports on topics including, for example, pilot age, alcohol and substance abuse, fatigue, psychology, and vision. FAA’s policy branch periodically reviews this and other medical literature, which FAA officials say can also result in a possible revision. http://www.faa.gov/data_research/research/med_humanfacs/oamtechreports/. In addition, FAA has recently begun analyzing aviation accident information to develop a predictive model based on historic data of medical conditions that have been identified as contributing factors to aircraft accidents. The officials stated that they plan to use the model as a data-driven guide to help inform how they determine the relative risk of various medical conditions. FAA officials noted that the agency has begun this work as part of a broader Safety Management Systems (SMS) initiative that seeks to further enhance safety by shifting to a data-driven, risk-based oversight approach. All aerospace medical experts we interviewed generally agreed that FAA’s medical standards were appropriate, and most (16 of 20) said that Some the standards should be applied to commercial and private pilots.of these experts said that standards should apply equally to private pilots because they share airspace with commercial pilots or because private pilots typically do not fly with a copilot—an important safety feature for commercial flight operations. In addition, although some of the experts (7 of 20) suggested no changes to FAA’s policies, many of the experts (13 of 20) identified at least one medical standard for which they considered FAA’s policies to be either too restrictive or too permissive. A restrictive policy might lead FAA to deny certification to an applicant who may be sufficiently healthy to safely fly a plane, or may result in FAA requiring a more thorough medical evaluation than the experts considered necessary. A permissive policy, on the other hand, might lead FAA to certify an applicant with health issues that could impair his or her ability to safely fly a plane, or may result in FAA not completing as thorough a medical evaluation as the experts considered necessary.