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certification, a history of repeated or clustered attacks will normally lead to loss of medical fitness. This is
based on the unpredictability of the episodes, their tendency to cluster, their variable symptomatology and
the risk of incapacitation for an uncertain length of time. However, some individuals suffer periods of
apparent vulnerability to such episodes but followed by long periods of freedom from attacks. This may
ICAO Preliminary Unedited Version — October 2008 III-1-47
allow certain individuals to eventually regain their Medical Assessment, normally with an enduring
restriction to multi-crew operations.
The aviation environment is one that is marked by fatigue due to disrupted sleep, circadian stress, and at
times high temperatures and humidity in places that are visited. There is also a significant risk of
gastroenteritis which may provoke an episode in a vulnerable individual.
Malignant and recurrent vaso-vagal syncope should disbar from all classes of medical certification.
Following a single episode of unexplained syncope, a full cardiological examination is required; a
neurological examination is necessary only if the diagnosis is subsequently unclear. Loss of
consciousness due to structural abnormality of the heart, or significant arrhythmia, will disbar. When
vasovagal syncope is the diagnosis, recurrence within 12 - 24 months is likely to result in a long term
unfit decision. However, due to the tendency of episodes to cluster, recertification may be possible after a
significant interval of freedom from attacks (arbitrarily two years) during which the pilot should remain
on the ground.
Restricted certification after a single episode may be permitted after an interval, arbitrarily of three to six
months with full certification no sooner than five years after the attack, provided there has been no
recurrence. Aircrew in whom the diagnosis has been made need to be counselled about the condition and
told when attacks are likely to occur and how to manage them should they do so.
Acknowledgement: Parts of this chapter have been reproduced from: David J. Rainford, David P.
Gradwell (Editors), “Ernsting’s Aviation Medicine” 4th edition (Arnold, 2006), by kind permission of the
publisher.
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Manual of Civil Aviation Medicine 1(105)
