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Further reading concerning questions for use by medical examiners
1) National Institute on Alcohol Abuse and Alcoholism, Alcohol Alert, Apr 2002
http://pubs.niaaa.nih.gov/publications/aa56.htm
2) Screening for alcohol problems in primary care: Fiellen, DA, Reid, MC, O`Connor, PG. Arch Intern
Med. 2000;160:1977-1989
3) Case-finding Instruments for Depression. Two questions are as good as many. Whooley, MA, Avins, AL,
Browner, WS. J Gen Intern Med. 1997 July; 12(7): 439-445.
4) Using five questions to screen for five common mental disorders in primary care. Means-Christensen, AJ,
Sherbourne, C, Roy-Byrne et al; General Hospital Psychiatry 2006; 28: 108-118.
5) Counselling Resource Welcome to the Drug Abuse Screening Test (DAST).
http://counsellingresource.com/quizzes/drug-abuse/index.html.
6) Manual on prevention of problematic use of substances in the aviation workplace, Document 9654;
International Civil Aviation Organization, Montreal, Canada, 1995
ICAO Preliminary Unedited Version — October 2008 I-3-8
FLEXIBILITY IN THE APPLICATION OF
ANNEX 1 MEDICAL REQUIREMENTS
The range of variation between individuals is such that if medical Standards are laid down in rigid terms,
they will inevitably exclude a number of applicants who, though not meeting the Standards in all respects,
might nevertheless be considered capable of performing duties safely in the aviation environment. Since
the Chicago Convention lays on Contracting States the duty to promote efficient and safe aviation as well
as to regulate it, provision has been made in Annex 1 for the exercise of a degree of flexibility in the
application of medical Standards, thus avoiding the hardship and injustice which might otherwise occur. It
is essential for the maintenance of flight safety that the manner in which flexibility is exercised should be
reasonably uniform throughout the Contracting States if international acceptance of licences is to be
maintained. In the past, flexibility has been used in widely differing ways by States. The application of
the principles set out in this chapter will assist in achieving uniformity.
The exercise of flexibility
1.2.4.8 If the medical Standards prescribed in Chapter 6 for a particular licence are not met, the appropriate
Medical Assessment shall not be issued or renewed unless the following conditions are fulfilled:
a) accredited medical conclusion indicates that in special circumstances the applicant’s failure to meet any
requirement, whether numerical or otherwise, is such that exercise of the privileges of the licence applied for
is not likely to jeopardize flight safety;
b) relevant ability, skill and experience of the applicant and operational conditions have been given due
consideration; and
c) the licence is endorsed with any special limitation or limitations when the safe performance of the licence
holder’s duties is dependent on compliance with such limitation or limitations.
The provision of a degree of flexibility must not lead to a situation where its use becomes the rule rather
than the exception. Annex 1, 1.2.4.8 has been worded to make it clear that flexibility may be exercised
only in the exceptional case. Failure to observe this requirement could result in routine approval of
individuals not meeting specific medical requirements, such as visual standards, thus creating an abuse of
the primary object of flexibility. When evidence accumulates that flexibility is being utilized repeatedly in
a particular respect, then the appropriateness of regulations defining the medical requirements comes into
question and the suspicion is raised that the regulations define a requirement which is not in keeping with
the demands of flight safety. However, when decisions to exercise flexibility are backed by an accredited
medical conclusion, it indicates that these decisions have not been regarded as a routine measure but that
they have been taken following close examination and assessment of all the medical facts and their
relationship to occupational demands and personal performance. The degree and intensity of investigation
lying behind each decision accurately measures compliance with the principles behind the flexibility
Standard.
The just and safe exercise of flexibility should be confined to the exceptional case and it ought to be
considered in relation to the expertise of those concerned in applying Annex 1, 1.2.4.8. As a consequence
“accredited medical conclusion” is a basic concept and has been specifically defined in Annex 1 as “the
conclusion reached by one or more medical experts acceptable to the Licensing Authority for the
purposes of the case concerned, in consultation with flight operations or other experts as necessary”. The
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Manual of Civil Aviation Medicine 1(21)
