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been discussed in connection with the ageing pilot, this is relevant to many other situations such as head
injury, depression, cerebrovascular disease, or problematic use of substances. Cognitive decline occurs
normally with age, but the rate and onset are not predictable, and it may present in aviation professionals well
before their typical retirement age. Whilst such decline might be better detected in an operational
environment (such as by simulator assessments or line checks) it may also be the medical examiner who is
first able to detect such changes. Competency in evaluating cognitive function would in such cases support
the required evaluation of psychiatric/psychological factors. The use of short-term memory tests, mini-mental
status questionnaires, and other simple office-based assessments can form an initial evaluation of cognitive
function.
2.2.9 Focus examination on risk areas relating to behaviour, specifically assessing for potential problematic
use of substances (such as alcohol, prescription and non-prescription medications, and non-prescription drugs
used for recreational purposes):
a) Explain the importance of problematic use of substances in the aviation workplace.
b) List features of problematic use of substances including the differences between abuse and
dependence.
c) Describe how prescription medication may result in problematic use.
d) Describe how non-prescription (over the counter) medication may result in problematic use.
e) List clues as to problematic use of substances.
f) Identify available tools for further evaluating problematic use of substances.
g) Outline processes for determining the likelihood of substance dependence.
h) Identify available management options for applicants with problematic use of substances.
Detection of problematic use of substances, including potential substance use disorders and particularly
substance dependence and substance abuse, is emphasised here. Substance dependence is accepted as a
medical condition under both the American Psychiatric Association’s DSM-IV and the World Health
Organisation’s ICD-10 (“dependence syndrome”) and its detection is made difficult by the characteristic
feature of denial. It is therefore suggested that medical examiners should be required to have a level of
competency in the detection and evaluation of substance use disorders. This should include familiarity with
ICAO Document 9654 – Manual on Prevention of Problematic Use of Substances in the Aviation Workplace
(1995).
The management of substance dependence in aviation is one demonstration of the value of open reporting
systems, in the form of programmes such as that known in the USA as the Human Intervention Motivation
ICAO Preliminary Unedited Version — May 2010 V-1-18
Study (HIMS). Prior to the 1970s a diagnosis of substance dependence, including dependence on alcohol, led
to permanent disqualification, with the consequence that detection rates were very low (due to failure of
individuals to admit they have a problem. The HIMS programme produced a pathway by which substance
dependent pilots could, with successful treatment and follow-up measures in place, be allowed to return to
flying in a supervised ongoing recovery programme. Well over 4000 pilots have been returned to flying
through HIMS in the past few decades (Hudson, 2009). Many other States have analogous programmes in
place. It is contended that medical examiners should have a sound understanding of such programmes and
their place in the management of substance use disorders in aviation.
Whilst it might be argued that this is merely a component of psychiatric and psychological evaluation, it is
emphasised separately here because of the disproportionate contribution of alcohol and other drug-related
issues in medical cause accidents (see Part III, Chapter 9 – Mental Fitness). It is suggested that these or
similar tools be incorporated into the training and competencies of examiners.
2.2.10 Focus examination on high risk areas pertaining to functional capacity, specifically sleep disorders
and fatigue:
a) Explain the importance of sleep disorders in commercial aviation.
b) List features of circadian rhythms, normal sleep patterns and common sleep disorders.
c) List appropriate questions to ask about sleep and fatigue.
d) List physical signs associated with sleep disorders.
e) Describe processes for further evaluating and treating a possible sleep disorder.
f) Describe how risk of fatigue can be minimized by sleep hygiene measures.
g) Describe how medication may be used to minimize fatigue risk, and precautions to be taken.
The final area which deserves highlighting is that of common sleep disorders, principally obstructive sleep
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Manual of Civil Aviation Medicine 2(155)
