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addition the individual should be regularly monitored by a diabetologist to exclude any
complications. Specifically, with the increased incidence of coronary heart disease in Type 2
diabetics, there should be a cardiovascular assessment to include, for example, an annual
exercise ECG to mitigate the cardiovascular risk.
ICAO Preliminary Unedited Version — March 2010 III-4A-5
Table 1
Hypoglycaemia Risk Among
Insulin users
• Stimulated C-Peptide levels > 25% of normal
• No previous hypoglycaemic reactions requiring the intervention of another
person.
• Stable blood glucose control as measured by:
(a) Glycated Hb (Patient /upper lab normal ratio <2.0.
(b) 90% of blood glucose measurements >5.5 mmol.L.
• Adequate self monitoring with a memory chip glucose meter.
• Good diabetes education and understanding.
• No evidence of hypoglycaemia unawareness
• Positive attitude to monitoring and self care.
C-peptide is an indicator of beta cell activity
Most Type 1 diabetics are C-peptide negative
Low Risk
6. Risk benefit analysis
The benefit to aviation of introducing this protocol would be to help maintain a high level of aviation
experience on the flight deck, with minimal risk to flight safety; many of these pilots have a wealth of
experience, as the majority of Type 2 diabetics do not present with failure to respond to oral
hypoglycaemic agents until they are between 40 and 50 years old. Pilots in this age group usually have
extensive flying experience and are likely to exhibit more mature judgement skills than their more junior
colleagues. By selecting Type 2 diabetics and returning them to the flight deck with a multicrew
limitation, the risk is further reduced due to the incapacitation training that commercial pilots are required
to undergo when operating on multi-crew flight decks. This risk can be further mitigated by a stipulation
that the pilot must inform his colleagues on the flight deck of the nature of his multicrew endorsement
and instruct them in actions should mild or severe hypoglycaemic events occur.
In any long haul operation there is ample time to check blood sugar levels at regular intervals and the
availability of carbohydrate is not a problem. In a short haul operation it is unlikely that the blood sugar
will change dramatically over a one to two hour period but at the midpoint of the flight, monitoring
should be carried out. Provided these interventions are given adequate attention, this approach has
potential benefit to the aviation industry as well as to the pilots concerned. It is, however, clear that any
licence holder who requres insulin for treatment must be carefully assessed and those who are believed to
be at low risk of complications must agree to cooperate fully with the Licensing Authority. The Authority
must be confident that all relevant reports will be supplied to it in a timely manner.
ICAO Preliminary Unedited Version — March 2010 III-4A-6
7. Monitoring procedures
It is essential that individuals who are accepted for this approach use a glucometer which is regularly
calibrated and has a memory chip. The pilot must carry a supply of 10 g portions of readily absorbable
carbohydrate to cover the duration of the flight. Prior to the flight the blood glucose must be greater than
6.0 mmol/L. During the flight the blood glucose should be monitored every 30-60 minutes, and if it falls
below 6.0 mmol/L, a 10 g carbohydrate portion should be ingested. If, for operational reasons, the
inflight blood glucose measurement cannot be done, then 10 g of carbohydrate should be ingested. The
frequency of monitoring during flights/duty periods over two hours may be reduced depending on
individual circumstances, in consultation with the diabetologist and an aviation medicine specialist.
Blood glucose should be measured approximately 30-45 minutes prior to landing and if the blood glucose
has fallen below 6.0 mmol/L, 10 g of carbohydrate should be ingested. With modern diabetic
management involving prandial bolus injections of insulin, it is reasonable on long haul flights to have
the diabetic pilot inject at appropriate times. In flights over 8 hours it is likely that the aircraft will carry
“heavy crew” (one or more pilots in addition to the minimum required to operate the aircraft) and thus
this should not present a significant problem. If, despite this approach, the blood glucose exceeds 15
mmol/L, medical advice should be sought in order that corrective therapeutic measures may be taken. A
standard operating procedure needs to be in place to deal with the situation when medical advice e.g. from
medical grouind support, may not be available.
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Manual of Civil Aviation Medicine 1(138)
