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In the course of decision making, it is frequently necessary to resort to other sources of information, such
as contributions from flight managers, employers, the family physician and, occasionally, members of the
family.
Whereas the standard medical examination procedures will normally provide all of the data required by
the medical examiner or the medical assessor of the Licensing Authority to take a decision on the
applicant’s fitness, occasionally more sophisticated tests will be required to enable an informed decision
to be made. The content of individual special examinations may very largely be determined by the
specialist who is carrying out the investigation, usually in consultation with the medical assessor of the
Licensing Authority.
Whenever possible, the risk of in-flight incapacitation, caused by an existing and diagnosed medical
condition, should be estimated as an annual percentage risk. This is particularly important when expert
medical advice is sought from medical specialists without aeromedical training and experience. In such
cases, every effort should be made to have the specialist evaluation expressed as an annual percentage
risk of recurrence, exacerbation, etc.
Whilst the expression of risk of in-flight incapacitation in numerical terms is not always easy to
determine, particularly for conditions that are uncommon, for a number of conditions such as certain
cardiovascular diseases, good data exist concerning the risk of a future related event. Many States have
determined that an acceptable risk of incapacitation for a professional pilot operating a multi-pilot aircraft
is one per cent per annum; some States even accept two per cent per annum. Where possible, ICAO
encourages the use of objective risk assessment for aeromedical fitness decisions as this acknowledges the
fact that zero risk is unattainable and provides a benchmark that protects flight safety and at the same time
is fair and transparent to the affected pilot. An acceptable level of risk can be developed by a regulatory
authority together with pilot representative bodies, thus providing the flying community with some input
into the decision-making process. The widespread adoption of such an approach would improve global
harmonization of aeromedical decisions. In this manual, an incapacitation risk of no greater than 1% per
annum has been taken as the basis for providing guidance on aeromedical fitness for professional pilots
operating multi-pilot aircraft. This is a relatively conservative figure and States that are familiar with such
risk assessments may wish to use a higher figure as their benchmark. However, for States not used to such
an approach, the “1% Rule” is reasonable. Further discussion of the “1% Rule” is in Part I Chapter 3.
Demonstration of the existence of a functional reserve would be an index of its importance in the
prognosis when the medical deficiency is considered to be relatively static and not subject to sudden or
insidious adverse changes.
The Licensing Authority should have resources or should have arrangements to permit special practical
ICAO Preliminary Unedited Version — October 2008 I-3-12
testing. One example is the medical flight test to allow an amputee to demonstrate his skill and
competence in adapting to the use of a prosthesis. If such an applicant has previously held a licence, it is
advantageous to conduct the subsequent flight test in an aircraft type with which the applicant is familiar.
It may be necessary, when flight competence has been demonstrated, to restrict the applicant to operating
the type of aircraft in which the applicant has demonstrated competence.
Medical flights or other practical tests can be utilized in a number of fields such as with applicants having
certain vision deficiencies (e.g. monocularity) or defective hearing. In these cases, the presence of a
medically qualified pilot on the check flight can add greatly to the value of the subsequent reports.
Licence limitations
It should be noted that Annex 1 does allow for medical Standards to relate to the specific duties that may
be undertaken by an individual licence-holder. This is indicated by relevant statements that appear in the
Annex text referring to safe operation of an aircraft or to safe performance of duties while exercising the
privileges of the licence. It follows that an applicant who has been assessed as unfit for one duty may be
found fit for another, and it is possible to envisage a Licensing Authority deciding that an individual
would be precluded from flying as a pilot while being judged capable of safely exercising the privileges
of a flight engineer’s licence.
It is evident that many such possible operational restrictions exist but they should only be established
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Manual of Civil Aviation Medicine 1(24)
