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posed by the possibility of an in-flight incapacitation. Grounding older pilots who have medical problems
may incur a high price in terms of sacrifice of pilot expertise. This might, paradoxically, have the opposite
effect of that desired because it is possible that flight safety would suffer if older experienced pilots with
minor health problems were replaced by younger and healthier, but less experienced pilots. At the same
time, it seems reasonable to assume that uneventful flying experience may breed complacency and also
that experience, obtained many years ago in aircraft types no longer flown and with navigational systems
and other equipment no longer in use, may be of little value today. Unfortunately, the data relating pilot
experience to risk of accident are sparse, although there is little evidence to suggest that the risk changes
much between 60 and 65 years of age, the latter limit becoming applicable (increased from 60 years) in
multi-crew aircraft in 2006. This is, however, not to say that refinements in aeromedical examination and
certification techniques should not be pursued.
It should also be mentioned that very demanding medical standards, at least ones that are perceived as
unjust by licence holders, may result in applicants withholding important medical information from the
medical examiner with a consequent decrease of flight safety. Since the medical history is more
important than the medical examination in eliciting conditions of flight safety concern, it is important that
an applicant believes he will be treated fairly, should he volunteer that he has a particular medical
problem. In cooperation with all stakeholders, including representative bodies of licence holders, States
ICAO Preliminary Unedited Version — October 2008 I-3-9
should strive to develop a “just culture” to minimize this risk.
Evidence-based decision making
A continued assessment of in-flight crew incapacitation as a flight safety hazard requires collection of
related data. Reporting of incapacitation incidents to ICAO is an integral part of an accident/incident
reporting system on a world-wide basis, but suffers from two major difficulties: firstly, the data are
incomplete as not all Contracting States send information on accidents and incidents, and secondly, the
data are rarely assessed and classified by personnel who understand the medical implications. Moreover,
Contracting States which have their own reporting system are often hampered by the confidential nature
of the information supplied. For example, a report following an incapacitation is often filed by another
crew member who does not reveal the name of the incapacitated person, making follow-up difficult.
Further, incapacitation data classified by means of a layman’s diagnosis may be incorrect or misleading: a
pilot who collapses with abdominal pain may be suffering from one of a number of medical problems, but
is likely to be diagnosed by other crew members as having a gastrointestinal upset. The diagnosis might
not be relevant at the time of incapacitation, but is important for monitoring medical standards and in
determining where the maximum benefit for a given effort is achieved with respect to reducing the
incidence of in-flight incapacitation. Attention needs to be given to devising a more accurate, preferably
international, method of recording and classifying data on in-flight incapacitations. In recent years ICAO
has taken the initiative to require a Safety Management System (SMS) to be incorporated into the routine
management of aerodromes, air traffic and airlines. An integral part of SMS is that of measuring and
recording safety events, and of setting targets. It is to be hoped that this development will provide the
stimulus towards a more evidence-based application of aeromedical standards.
CONCLUSIONS
In-flight pilot incapacitation is an air safety hazard and is known to have caused accidents. Such
incapacitation occurs more frequently than many other emergencies that are routinely trained for, such as
sudden decompression. Incapacitation can occur in many forms, ranging from sudden death to a not easily
detectable partial loss of function, and has occurred in all pilot age groups and during all phases of flight.
It is important to recognize the operational ramifications of pilot incapacitation. Medical officers working
for regulatory bodies should be fully aware of the operational aspects.
Instruction and training of flight crew concerning action in the event of in-flight pilot incapacitation
should include early recognition of incapacitation as well as the appropriate action to be taken by other
flight crew members.
REFERENCES
Booze, C.F., “Sudden In-Flight Incapacitation in General Aviation,” Report Number
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Manual of Civil Aviation Medicine 1(54)
