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risk).
The frequency of actual in-flight incapacitations is not known (De John, 2004) and in order to gain better
information, ICAO has adopted a recommendation that States establish mechanisms to collect data on inflight
incapacitation (ICAO Annex 1, paragraph 1.2.4.2, applicable November 2010). The chief protection
against incapacitation in air transport aircraft is the presence of a second pilot, coupled with the training of
pilots in dealing with an incapacitation emergency (De John, 2004). Similarly with air traffic controllers,
protections exist when multiple controllers and supervisors can detect incapacitation and take over duties.
However, risk of incapacitation occurring from some unexpected event is only one of the areas evaluated in
the aviation medical examination. Others include:
- assessment of functional ability to conduct aviation duties. Obvious examples include impairment of
vision, hearing or mobility. Assessment of such functions requires application of standards and
consideration of the aviation environment in which the individual may be working;
- assessment of conditions which may deteriorate because of the flight environment and thus impair
flight safety. For example, an applicant with asthma could remain well on the ground, but experience
an acute exacerbation when exposed to reduced oxygen pressures and cold temperatures associated
with an explosive decompression at altitude. Alternatively, a pilot who has recently had a retinal
detachment treated by injecting gas into the eyeball, will be at risk of adverse effects on vision if
exposed to altitude;
- assessment of conditions which may be aggravated by the work environment. Examples include
hearing loss which could be accelerated by exposure to noisy aviation environments. This is a
slightly different consideration, related more to the occupational health of the individual than directly
to the safety of flight – such aspects involve the effect of work on health, rather than the effect of
health on work. It is arguable whether protection of the health of an individual is an appropriate
objective of the regulatory authority, but in practice it is almost certain to be encompassed within the
medical examination process.
In addition, two other processes may be considered. The first is the provision of health advice (for example,
discussion of lifestyle factors such as smoking and exercise). Whilst it may be argued that this is not strictly
the role of the aviation medical examiner, many medical practitioners, and applicants, would consider it
appropriate, indeed best practice, to discuss such factors as they arise in the course of the medical examination
process, and advice on these factors may be relevant to the future fitness of the applicant for aviation duties.
The second process is that of building rapport between examiner and applicant, to facilitate declaration of
medical conditions or events. At the time of the medical examination, the applicant answers direct questions
about such aspects, but since such examinations tend to occur annually or less, most medical conditions arise
in between medical examinations, and the processes for reporting them (including use of medications) are
generally less regulated than those for the periodic medical assessments. Thus it is the pilot or air traffic
controller who must decide whether to notify the Licensing Authority, and the degree of rapport with the
medical examiner may be a factor in his decision.
ICAO has made inroads in this area, and has introduced a recommendation regarding reporting illness on
ICAO Preliminary Unedited Version — May 2010 V-1-9
occasions other than the routine medical examination:
“States should ensure that licence holders are aware of physical and mental conditions and
treatments that are relevant to flight safety. They should provide guidance concerning those
circumstances when medically related information should be forwarded to the Licensing Authority”
(Annex 1 Chapter 6, paragraph 1.2.6.1.1).
Handling such reporting should, at least in some States, be a competency of medical examiners so that they
can make sound decisions on whether a pilot may continue to fly with a certain condition or treatment.
COMPETENCY FRAMEWORK
Explanatory notes
1. Structure
The competency framework has four tier levels:
0. Competency Unit (“The main processes are…”)
0.0 Competency Element (“The steps within those processes that a competent designated medical
examiner is expected to take are…..”)
0.0.0 Performance Criteria (“The DME will normally be expected to perform ……”)
0.0.0.0 Evidence and Assessment Guide (“At the completion of training, the examiner will be able to
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Manual of Civil Aviation Medicine 2(149)
