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apnoea. The potential flight safety consequences of somnolence are evidenced by a 2009 case of two pilots
overflying their destination while asleep (NTSB 2008), which has been linked in part to a diagnosis of sleep
apnoea in one of the pilots. Sleep apnoea is probably significantly under-diagnosed in commercial aviation as
it is in drivers (Krieger, 2007) and is likely to be missed unless specific questioning is undertaken on
symptoms such as snoring, observations on breathing by the bed partner, daytime sleepiness and nocturnal
sweating, and the examiner should be extra vigilant in applicants with a large neck circumference. This is
therefore one area which should be noted carefully on physical examination
The use of hypnotics by applicants is also an issue that needs to be addressed during training. Many
Licensing Authorities accept that such medication has a place in regulatory aviation medicine, but clearly
some hypnotics are unsuitable. Topics that should be addressed are:
• Acceptable medications
• Relevant pharmacology e.g. duration of effect
• Minimum time required between ingestion and reporting for duty
• Need for licence holders applicants to avoid ‘over the counter’ or unsupervised treatment
• Requirement for those providing advice to licence holders to fully understand the operational context
of licence holders
ICAO Preliminary Unedited Version — May 2010 V-1-19
Part III, Chapter X – Fatigue and sleep disorders provides further information concerning sleep disorders and
fatigue.
2.3 Conduct and interpret results of routine investigations required by the licensing authority
Ancillary reports are received in association with the medical examination and need to be interpreted by the
examiner. In some States these may be numerous, but as a minimum, examiners will be receiving
electrocardiograms, audiometry (in most States) and in some cases, vision reports. These relate to key organ
systems and a degree of expertise in their interpretation should be expected of medical examiners.
2.3.1 Conduct and interpret electrocardiograms:
a) Identify the licensing authority’s requirements for conducting electrocardiograms.
b) Describe how to prepare applicant and set up equipment.
c) Describe how to optimize electrode contact and avoid interference.
d) Demonstrate the correct positioning of leads and how to identify lead reversal.
e) Identify common normal electrocardiographic variants.
f) Identify important disturbances of rate, rhythm and axis such as heart blocks, atrial fibrillation,
supraventricular tachycardia, and bundle branch blocks.
g) Identify left ventricular hypertrophy.
h) Identify old or recent myocardial infarction, and current ischaemia.
2.3.2 Interpret pure-tone audiometry (or alternative methods of assessing hearing):
a) Identify the licensing authority’s requirements for conduct of audiometry.
b) Describe how pure-tone audiometry is undertaken.
c) Explain temporary threshold shift and its importance.
d) Identify significant hearing loss.
e) Identify asymmetric hearing loss and describe its importance.
f) Describe how to distinguish conductive from sensorineural hearing loss.
g) List potential causes of conductive hearing loss.
h) List potential causes of sensorineural hearing loss
i) Identify follow-up actions for various causes of hearing loss.
j) Describe alternative methods of assessing hearing and their merits.
ICAO Preliminary Unedited Version — May 2010 V-1-20
2.3.3 Interpret vision testing:
a) Identify the licensing authority’s requirements for vision testing.
b) Identify the applicable standards for distance and near vision.
c) Explain myopia, hyperopia (hypermetropia), presbyopia and astigmatism.
d) Correctly interpret refractive errors from ophthalmology or optometry reports.
e) Explain the importance of phorias to flight safety.
f) Describe the features of spectacles and contact lenses.
g) List flight safety concerns with common spectacle and contact lens types.
h) List flight safety concerns with common types of refractive surgery.
2.4 Request and interpret additional investigations and reports, as indicated
On the basis of findings from history, examination or routine investigations, the medical examiner may
request and organise further investigations. This process requires the application of skills which are
fundamental to medical practice, using an understanding of the patterns of findings from history, examination,
and routine investigations, and formulating new questions to be answered by further investigation.
2.4.1 Recognize common patterns from clinical findings which suggest the need for further examination:
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Manual of Civil Aviation Medicine 2(156)
