President’s Corner, 3Q14, “Fit to Fly? How Can We Know?” Part 2

by Quay Snyder, MD, MSPH

In our previous newsletter, I discussed personal preflight self assessment techniques to determine if a pilot is fit to fly and can operate an aircraft safely. I also highlighted the recent efforts of the NBAA’s Safety Committee to educate flying professionals about their 2014 Safety Focus Area on Fitness For Duty (FFD). This month, I will address surprising observations and dispel common misperceptions about the “unfit” pilot.

Pilots with flying or training problems are referred to our office, either by their aviation department leadership or sometimes self-referred, to determine if they have an explainable reason for the apparent deterioration in flying skills, be it handling the aircraft, programming the FMS, following SOP’s, ineffective communications, poor CRM techniques, physical inabilities or possible cognitive impairment. In all cases, the concern is both for the safety of flight operations and for the health of the pilot.

The challenges in recognizing this possible unfit condition are many. Unfortunately, not recognizing or delaying investigation is harmful to both flight operations and to the pilot’s physical and mental health. To not investigate in an industry where safety is a key concern is unethical for all concerned.

Potential barriers in the cockpit is a culture of covering for other pilots and long time flying friends, the fear of loss of income or passionate avocation, rationalization that the pilot is just having a “rough spell.”, the thought that a fellow pilot can handle the deficiency adequately, concern over FAA action or simply a reluctance to speak up and get involved in another pilot’s difficulties.

Management’s challenges include fear of a legal actions or discrimination suits for older pilots, privacy concerns, the absence of written guidance or company policy to address this, mission demands on the flight department, lack of insurance coverage or disability programs, an internal medical staff not trained to deal with the nuances of aviation health, the feeling that this is someone else’s responsibility and the absence of aeromedical expertise to consult with.

For affected pilots, most will not recognize potential impairment, particularly in the early stages. We are problem solvers who can get the mission done and are inclined to minimize the impact of adverse situations, even if we recognize the potential for compromised abilities. Denial is a powerful protective mechanism in the proper context, but can be fatal if imminent dangers to our own abilities are not recognized.

AMAS has designed a program to maintain the dignity and medical privacy of the pilot, investigate potential health and emotional factors that would result in substandard performance, and recognize cognitive problems. The company is protected by using an independent third party with aeromedical expertise, using FAA medical standards to determine fitness in a comprehensive fashion. The company is only informed of the pilot’s medical qualification status, not particular diagnoses or treatments, thus preserving the pilot’s dignity while protecting the company from having an unfit pilot in the cockpit.

Very surprisingly, in over three dozen evaluations done in the last several years, most pilots referred were found to have treatable medical, psychological and cognitive conditions that could be successfully treated, with the pilot returning to flying after FAA clearance as a safe, productive member of the flight crew.

Approximately two-thirds of pilots returned to flying after evaluation and treatment. A small number were found to have progressive, permanently disqualifying conditions, such as Alzheimer’s disease or neurological conditions similar to Lou Gehrig’s disease. Several pilots recognized their unfit condition after it was called to their attention and elected to remain out of the cockpit while their lengthy successful careers were recognized by the company. They avoided termination for failure to meet standards and instead retired with the appropriate disability benefits.

What are the most common conditions that result in referral because of fitness concerns? Many are unrecognized by the pilot or even the physicians and AME’s. The good news is with recognition comes the opportunity for successful treatment and return to a productive and safe flight environment.

Medical conditions included use of medications that may cause sedation or cognitive impairment, even if they are allowed by the FAA and not usually known to occur in most users. Discontinuing the medication results in a return to normal mental function. The NTSB announced its Safety Study 14/01 on medication side effects in early September. Titled “Drug Use Trends in Aviation- Assessing the Risk of Pilot Impairment”, the study showed an alarming use of impairing medications and/or flying with impairing medical conditions in fatal aviation mishaps form 1990 through 2012. The trend of use of prescription medications, over the counter medications and illicit drugs is rising in all age groups of pilots.

Obstructive sleep apnea was a common, unrecognized condition. Once treated the pilots had significant improvement in alertness, memory, mood and cognitive functions. Not only did the pilots recognize this, but the spouses did also. Heart / lung problems and anemia leading to hypoxia and reduced physical capability in flight, which are treatable were discovered. One pilot had heavy metal toxicity from living near a mine that was successfully resolved. Hearing loss, cataracts, migraines and diabetes are other treatable conditions identified in the evaluation.

Psychological issues were identified in about one-third of the referred pilots, all unrecognized or denied. Most resolved with counseling and few required medication. Unresolved grief reactions, PTSD for combat flying operations and aircraft accidents, severe depression, unhelpful personality traits and family stressors related to divorce and child rearing challenges all responded successfully to counseling.

Pilots are unmatched in their ability to compartmentalize outside problems when in the cockpit, but when the psychological bucket is overflowing, pilots are the last ones to recognize that their performance is compromised and initially deny it if someone asks if they are OK. A program to evaluate these conditions gives the pilot the dignity to recognize, discuss and treat these tragic situations and return not only to the cockpit, but to life, as a healthy happy person.

The third category in which medical causes of impaired flying were identified was in the cognitive arena. All people experience a gradual decline in cognitive function with age. Some start from a higher baseline and others have a slower decline than the average person. In most cases, pilots develop compensatory mechanisms to continue to perform adequately. When those compensatory techniques are no longer adequate, safety is compromised and others begin to have concerns.

Fortunately, some cases of cognitive decline respond to very well studied cognitive conditioning programs with dramatic improvements in testing scores and day to day functional abilities. These pilots successfully return to the cockpit and continue to work out in their “cognitive gymnasium” just as they would in a fitness center for their physical health.

A small group of pilots are identified with diseases such as Alzheimer’s or a brain tumor or serious stroke. Unfortunately, they will not be able to return to flying. However, rather than being the cause of a dangerous situation or being terminated for failure to fulfill job responsibilities, they obtain appropriate medical care and preserve their health care benefits and disability programs instead of facing termination.

Several of my colleagues and I working with the NBAA Safety Committee’s Fitness For Duty Working Group will give a detailed presentation on this subject at the NBAA convention on Wednesday 22 October at 9 AM. I encourage all who are interested to attend. I will be available to respond to questions for several hours after the presentation. Contact AMAS by email if you have any questions and cannot attend the presentation.

Fly Safely, Stay Healthy!