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of what level of safety is practically available.”
Medical screening, by itself, cannot be relied upon to reduce the hazard of incapacitation to an
acceptable minimum level, even if significantly more rigorous medical standards were to be
ICAO Preliminary Unedited Version — October 2008 I-3-5
applied. Other important aspects, over which medical examiners have little direct control, include
pilot education in the causes of incapacitation, pilot training for safe handover of controls in such
an event and, especially, good food hygiene and low-risk, separate meals for the fight crew. From
the operational/training viewpoint, the maxim that “any pilot can become incapacitated at any
time” is relevant.
Pilot incapacitation training
Pilot training in the early recognition of incapacitation and in safe handover of controls, pioneered in the
United States, has been highly effective in preventing accidents from physical incapacitation. It seems
less effective in the case of mental incapacitation. Because the majority of accidents result from human
failure of some sort, degradation of performance from commonly occurring sub-clinical conditions such
as mild anxiety and depression, sleep loss and circadian rhythm disturbance is an important factor in this
area of relative incapacitation. Although mostly a small problem amongst flight crew, the problematic use
of psychoactive substances is likely to become more important as their general use in society increases.
Incapacitations can be divided into two operational classifications: “obvious” and “subtle”. Obvious
incapacitations are those immediately apparent to the other crew members. The time course of onset can
be “sudden” or “insidious” and complete loss of function can occur. Subtle incapacitations are frequently
partial in nature and can be insidious because the affected pilot may look well and continue to operate but
at a less than optimum level of performance. The pilot may not be aware of the problem or capable of
rationally evaluating it. Subtle incapacitations can create significant operational problems.
A series of 81 simulated obvious and subtle incapacitations showed that pilots needed help in two areas:
their first need was for a method of detecting subtle incapacitations before they became operationally
critical; their second need was for an organized method of handling the incapacitations once they were
recognized. It was learned that all pilot incapacitations create three basic problems for the remaining
crew. This is true whether the incapacitation is obvious or subtle and whether there is a two- (or more)
member crew. Although this study was carried out many years ago, its recommendations are still valid. If
an in-flight incapacitation occurs, the remaining flight crew has to:
a) maintain control of the aircraft
b) take care of the incapacitated crew member
(An incapacitated pilot can become a flight deck hazard and, in any case, is a major distraction to
the remaining crew. For this reason, responsibility for the incapacitated pilot, who should
preferably be removed from the flight deck, should be given to the cabin crew)
c) reorganize the cockpit and bring the aircraft to a safe landing.
These three steps became the organized plan for handling in-flight incapacitation. They should be taken
separately and in order.
“Two communication” rule
The “two communication” rule was developed to meet the need for a method of detecting subtle
incapacitations before they become operationally critical. The rule states: “Flight crew members should
have a high index of suspicion of a “subtle” incapacitation any time a crew member does not respond
appropriately to two verbal communications, or any time a crew member does not respond appropriately
to any verbal communication associated with a significant deviation from a standard operating procedure
or a standard flight profile.” This rule is easy, straightforward, and effective.
ICAO Preliminary Unedited Version — October 2008 I-3-6
Cognitive incapacitation
A particular category of incapacitations has been identified as “cognitive.” The problem created by these
incapacitations is how to deal with a pilot who is “mentally disoriented, mentally incapacitated or
obstinate, while physically able and vocally responsive.” In this category, the captain presents the most
difficult case.
While cognitive incapacitations may seem to be psychologically based, in some cases the underlying
causes are pathological, as with a brain tumour, causing an erratic performance. Retrospectively, there
often seems to have been ample warning of an impending problem. In most cases of cognitive
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Manual of Civil Aviation Medicine 1(51)
