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because the decision to apply the clause is only reached after subjecting the individual involved to a
critical analysis, possibly involving detailed personal examination together with deliberations by those
who formulate the “accredited medical conclusion” and the decision of the Licensing Authority. What
Annex 1, 1.2.4.8, sets out to achieve is not the dismissal of a deficiency or discrepancy, but establishment
of the fact that allowing a particular individual to exercise the privileges of a licence with or without the
imposition of certain limitations on his activities will not be incompatible with the requirements of flight
safety. Consequently, the issuance of a licence based on a Medical Assessment following an accredited
medical conclusion under the provisions of paragraph 1.2.4.8 does not constitute a departure from the
international Standards and Recommended Practices, and no endorsement of the license is required under
article 39 b) of the Convention on International Civil Aviation.
The Licensing Authority and accredited
medical conclusion
1.2.4.4 Contracting States shall designate medical examiners, qualified and licensed in the practice of
medicine, to conduct medical examinations of fitness of applicants for the issue or renewal of the licences or
ratings specified in Chapters 2 and 3, and of the appropriate licences specified in Chapter 4.
1.2.4.4.1 Medical examiners shall have received training in aviation medicine and shall receive refresher
training at regular intervals. Before designation, medical examiners shall demonstrate adequate competency in
aviation medicine.
1.2.4.4.2 Medical examiners shall have practical knowledge and experience of the conditions in which the
holders of licences and ratings carry out their duties.
Note.— Examples of practical knowledge and experience are flight experience, simulator experience, on-site
observation or any other hands-on experience deemed by the Licensing Authority to meet this requirement.
1.2.4.4.3 Recommendation.- The competence of a medical examiner should be evaluated periodically by
the medical assessor.
. . .
1.2.4.7 Contracting States shall use the services of medical assessors to evaluate reports submitted to the
Licensing Authorities by medical examiners.
1.2.4.7.1 The medical examiner shall be required to submit sufficient information to the Licensing Authority to
enable that Authority to undertake Medical Assessment audits.
Note.— The purpose of such auditing is to ensure that medical examiners meet applicable standards for good
medical practice and aeromedical risk assessment. Guidance on aeromedical risk assessment is contained in
the Manual of Civil Aviation Medicine (Doc 8984).
Medical examiners designated by Contracting States are authorized to conduct examinations for the
assessment of medical fitness. When the medical requirements are not met, it is the duty of the Licensing
Authority concerned to take any necessary steps. The medical examiner is called upon to exercise clinical
judgement based upon a careful review of the medical history and a thorough examination of the
applicant. The examiner shall report to the Licensing Authority any individual case where, in the
examiner’s judgement, an applicant’s failure to meet the medical requirements does not adversely affect
safety, with due consideration given to any relevant ability, skill and experience. The final decision must
be left with the Licensing Authority which is ultimately responsible for flight safety. This authority either
ICAO Preliminary Unedited Version — October 2008 I-3-11
has an aviation medical section with permanent medical advisers – medical assessors – or an
administrative machinery for obtaining expert aviation medical advice on individual cases from external
medical assessors. Either method meets the requirements of paragraph 1.2.4.7 of Annex 1 and provides
the “accredited medical conclusion” as defined in paragraph 1.2.4.8 of Annex 1. The decision of a
Licensing Authority to exercise the “flexibility” clause of Annex 1 should be documented in each
individual case and it should show how a particular decision was arrived at by means of the accredited
medical conclusion.
Steps should be taken to gather information on the number of instances where flexibility is exercised and
on the clinical conditions to which the clause is applied. Contracting States have been encouraged to
furnish ICAO with information, periodically, on the application of the “flexibility” clause to applicants
for initial issue and renewal of a licence, with particular reference to the paragraph in Annex 1 to which
the provisions of 1.2.4.8 have been applied and the reason for such a decision.
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Manual of Civil Aviation Medicine 1(23)
