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Class 1 Medical Assessment with an operational multi-crew limitation (OML) thereon. Note that not all
Contracting States utilise the OML concept, and in such States an applicant may be assessed either as
unfit or as fit for unrestricted certification whereas in those utilising an OML, the same individual would
be allowed to fly with such a restriction applied to the licence, for example, following recovery from a
myocardial infarction.
The development of cardiological experience
Thirty years ago, a number of reports on cardiovascular problems were sponsored by the aviation
regulatory agencies in some Contracting States. These included the Federal Aviation Administration
(FAA) in the United States, the Civil Aviation Authority (CAA) in the United Kingdom, and the Civil
Aviation Authorities of Canada and Australia. Their purpose was to address the need for appropriate
scientific data to assist in making aeromedical decisions more consistent and fair. The United Kingdom
and European Workshops in Aviation Cardiology, four in number over a 16 year period between 1982
and 1998, focused on the epidemiology, natural history and outcome of most of the commonly
encountered cardiological problems. From them a methodology was evolved which was coherent with the
man-machine interface in regulatory terms. The pilot was identified as one component in an aviation
system, the failure of any part of which would lead to an erosion of safety with the ultimate potential risk
of catastrophic outcome.
Accidents are most commonly the result of a series of adverse events, which may include cardiovascular
incapacitation, none of which in isolation needs to lead to disaster because of safety redundancy in the
system. Taking these aspects into account, the workshops formed the basis of the first and second drafts
of the European Joint Aviation Authorities (JAA) Joint Aviation Requirements - Flight Crew Licensing
(JAR - FCL) Part 3 (medical) in cardiology and contributed by providing a cardiological “road map” in
regulatory terms. Since the 1990s, this material has been used as guidance by many regulators outside
Europe. The guidance contained in this chapter is based on recommendations that have been found
acceptable to the JAA.
ICAO Preliminary Unedited Version — October 2008 III-1-3
Determination of the limits of cardiological certification
There should be separation between the regulator and the specialist advisor (in cardiology). The
cardiologist is required to identify the probability of a cardiovascular event in a given individual over a
defined period. It is for the regulator to set a cut-off point for the cursor which denies, or restricts,
certification. In general terms, the following questions need to be satisfied:
• What is the operational exposure? This may be expressed in terms of number of hours flown,
number of departures, or number of passenger-kilometres travelled.
• What is the fatal/non-fatal accident rate expressed in the same units? Accidents are often
expressed per one million hours flown or per one million departures, but they can also be
expressed per unit of time, usually one year.
• What is the medical (cardiological) contribution to this accident experience, and is it acceptable?
Such data may be difficult to come by with certainty in the single-crew situation, because such
accidents are less well investigated than those involving large aircraft: the finding of a cardiac
abnormality in the context of an otherwise unexplained accident does not necessarily imply cause
and effect.
• What level of routine medical examination is appropriate, what is its sensitivity, and is it costbeneficial,
bearing in mind the parallels with regular airframe/engine review? What additional
investigations can reasonably be requested?
• Should there be an explicit cardiovascular level of risk, which, if exceeded by an individual,
results in denial of certification to fly? Without such a defined limit, there is the chance of
inconsistency, of lack of objectivity and fairness. However, not all Contracting States utilise an
objective limit in assessing risk, and of those which do, not all publicise what it is.
Aviation and cardiovascular risk
Aviation is involved with risk of event. Airframes have a predicted number of hours of “life”, and
engines have a “time before overhaul”. This proscription attempts to reduce the possibility of failure to a
predetermined target level in the interest of safety. The same applies to the heart of a pilot. At a young age
the probability of a cardiovascular event is very remote. In the four decades from age 30–34 to 70–74
years, male cardiovascular mortality in the Western nations increases by a factor of 100 (two orders of
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Manual of Civil Aviation Medicine 1(69)
