The Work of the Aviation Medical Examiner
Dr. Martin F HudsonMBBS, MRCP(UK), FRCP Edin.
Immediate Past Chairman of the Association of Aviation Medical Examiners
Authorised Medical Examiner for UK CAA, EASA, FAA (USA), CASA (Australia),Transport Canada
Company Medical Adviser Thomas Cook Airlines
June 2011
The Main Priorities
• To assess the physical and psychological fitness of Aircrew and Air Traffic Control Officers to fulfil safely their role in aviation
• To comply with the requirements of the regulations of the relevant licensing authority
Who do we examine?• Class 1 Commercial Pilots - Renewals, Re-validations.
NB All initial Class 1 performed at AMS, i.e. CAA Gatwick
• Class 2 Private Pilots - Initial, renewals and Re-validations
• European Class 3 ATCO• UK Class 1 Flight Engineers, Flight Navigators, Flight
Information Service Officers, Aerodrome Control Officers, Commercial Balloon Pilots,Commercial Airship Pilots,Class 2 Private Balloon Pilots
Who are the examiners?
• Aviation Medicine Specialists• Occupational Health Physicians• General Practitioners• Private Practitioners• Consultants• Military Medical Officers
Availability
• Commercial pilots: Available to all air-lines and aviation commercial organisations
• Pilot’s freedom of choice• Private Pilots• Information not advertising• Web-sites: information and on-line booking• e-mail
Appointment as an Authorised Medical Examiner
• Appointed by the CAA or relevant authority• Guaranteed appointment if suitably qualified• No upper retirement age • No waiting lists• Initially appointed for Class 2 only then up-graded
to Class 1 after a period of time and on completion of further training and examinations
Accreditation as an AME
• Interest and experience in Aviation Medicine/Armed Forces
• Basic Certificate in Aviation Medicine (minimum of 60 hours) Class 2
• Advanced Aviation Medicine Certificate (minimum of 120 hours) Class 1
• Diploma in Aviation Medicine • Flying experience, CPL, ATPL, PPL, NPPL
Appointment as an AME
• Class 1 requires minimum 6 points• Class 2 requires minimum 4 points• 3 points for completion of higher training• 2 points for Dip. Av. Med.• 1 point for 1 year work in aviation medicine
practice• ICAO PPL or NPPL 1 point• ICAO CPL or IR 2 points
History of AME Training Courses
• General Aviation Course (Farnborough) GAM: 5 days started 1973
• Initially linked with Aviation Medicine Course for Armed Forces MOs.
• 1984 expanded to 10 days• 1998 IAM Farnborough closed• 1998 Kings College, London - Advanced and Basic
Courses.• Diploma in Aviation Medicine
Other Aviation Authorities
• EASA (European Aviation Safety Agency)• FAA (American)• CASA ( Australian)• Canadian• Singapore• Others: e.g. China, Hong Kong, New Zealand,
UAE, South Africa, Middle East• ? Global harmonisation
The Medical Examination
• Appointments• Consulting room(s)• Lighting• Administration/secretarial/financial• Nursing assistant• Computerisation - Internet - e-mail• On-line transmission of medical examination
Equipment
• Basic examination instruments• Couch • Stethoscope• Auroscope + speculae• ? (Aural syringe) NB Medico-legal• Ophthalmic equipment• Torch
Equipment• Height measure and weighing scales• Sphygmomanometer ?Mercury,Aneroid,Automatic (NB
validation and calibration) • Audiometer (NB annual calibration)• 12 lead ECG with computerised interpretation (? +
modem capability)• Haemoglobinometer (calibration)• Urine testing kit (Hema-combistix)• Venepuncture (laboratory facilities)• Peak flow meter
Ophthalmic Equipment
• Snellen Charts; 6 metres and 1 metre (use of mirror is permitted to achieve distance)
• RAF Near Point Rule• Ishihara plates (24): 15 to be read correctly• Maddox rod/wing (phoria testing) + light• Ophthalmoscope• Eye mask/cover and Pin Hole disc• Vision tester e.g. Titmus
The Examination
• The History
• The Clinical Examination
• Investigation
The Medical History• Initial: All previous medical/surgical/psychological• Revalidation/Renewals: Recent events (since last
examination)• Recreational drugs - alcohol, tobacco,others• Medications - OTC, Prescribed• Check pilot’s entries and accuracy on application form.
N.B.’tickitis’!!!• NB Thoroughness, deliberate omissions, non deliberate
omissions, life-time not just recent for initial examinations
Physical/psychological fitness
• Exercise• Diet
• Hobbies• Commuting
• Family• Sleep
• Fatigue
Psychological History
• Stress - work and domestic ? Second jobs• Anxiety• Sleep history, Fatigue, Epworth sleep scale, sleep
apnoea• Depression; ? use of depression scoring
questionnaires• Alcohol problems / use of CAGE questioning• Drug dependency• ‘Gut-reaction’
Epworth Sleepiness Scale• How likely are you to doze off in the following situations in
comparison to feeling just tired?• 0 = never; 1 = slight chance; 2 = moderate chance; 3 = high chance• Sitting and reading• Watching TV• Sitting inactive at a meeting• Passenger in a car for an hour with no break• Lying down to rest in the afternoon • Sitting and talking to someone• Sitting quietly after a lunch without alcohol• In a car, while stopped for a few minutes in traffic
The Physical Examination• Careful full routine clinical examination• Use examination to prompt more history from pilot. i.e.
palpation of liver/auscultation of chest• Ophthalmic: uncorrected and corrected, contact lenses and
spectacles• ENT ? Valsalva maneoeuvre• Other examinations as clinically indicated• ? Rectal• ? Breasts and genitalia• NB Chaperone strongly recommended. GMC/CAA consider
this is essential
Ophthalmic standards• Myopia for initial Class 1: +5 to – 6• Myopia for renewal/revalidation; no limits• Astigmatism (irregular shape of the
cornea)/Anisometropia (unequal refractive power of the eyes) initial Class 1: 2 dioptres
• Astigmatism/Anisometropia no limits for Class 2 and for Class 1 renewal/revalidation
• Esophoria Class 1 limits now 8 prism dioptres• Amblyopia V/A in non amblyopic eye must be 6/6
corrected or uncorrected
Comprehensive Ophthalmic Examination for pilots with high degree of refractive error (RE)
• Not required for RE up to +3 to – 3• Required every five years for Class 1 pilots with
RE +3 to +5 or –3 to –6 • Required every 2 years for Class 1 pilots with RE
> - 6• Anisometropia and/or astigmatism of 3D requires
2 yearly ophthalmic review• CAA Optometrist’s Excel calculator available on-
line for checking exact requirements
Comprehensive Ophthalmic Examination for pilots with high
degree of refractive error• Performed by any Optometrist• Includes refraction, slit lamp, • Tonometry IOP (> 40 years of age)• *Colour vision (Ishihara 24/15 plates),
phoria,visual fields, fundoscopy• * Initial examination only for CAA but each
medical for FAA, Canadian, CASA
Comprehensive Ophthalmic Examination for ATCO’s, Flight
engineers, navigators
• Required at initial examination• Colour perception• Phorias
European Class 3 (ATCO)Periodic Requirements
• Comprehensive ophthalmic examination every two or five years depending on refraction level
• Tonometry every 2 years• Haemoglobin every 2 years
JAA Class 1 or Class 2 Visual Limitations Endorsements
• 2 VDL; Vision Distance Limitation (shall wear corrective lenses and carry a spare set of spectacles) [myopia]
• 3 VNL; Vision Near Limitation (shall have available corrective lenses) [presbyopia]
• 4 VCL; Flights only within JAA airspace. VFR flights by day only (colour vision defects) Class 2 PPL only.
Spectacles/contact lenses requirements
• 3 VNL for presbyopia look over or varifocal with no upper lens correction + back up
• 2 VDL with no presbyopia correcting spectacles or contact lenses + back up spectacles. NB Not back up contacts lenses
• 2 VDL + VNL; varifocals,bifocals,trifocals or contact lenses + look over half rim
Limitations for European Class 3 ATCO
• APC Standard proximity condition• ATL Valid only while wearing correcting spectacles
for ATCO licence (distance vision)• AUD Annual audiogram required• CLL Valid only while wearing contact lenses with
alternative spectacles available• RLL refer to limitations on licence• IGR Issued under ‘grandfather rights’• VSA Valid only when corrective spectacles available
(near vision requirement)
Spectacles/contact lenses requirements
• No photochromic lenses. Tinted lenses OK• No varifocal or near vision contact lenses or mixed
contact lenses• Check vision uncorrected and with both contact
lenses and spectacles• Back up MUST be same prescription. Not ’old’ pair
of spectacles• Annual or bi-annual check with optometrist advised
even if not CAA requirement especially over 40 years of age, NB Tonometry advised
Refractive surgery
• Generally not recommended for pilots• 3 month flying ban post operation• Detailed ophthalmic reports required• Class 1 pre-op limit – 6• Class 2 pre-op limit – 8• Post operation complications may occur ,
glare, distortion, pain, corneal complications
ENT examination
• Visualise Tympanic membrane• ? Removal of wax• Valsalva and patency of Eustachian tubes• Nasal airway assessment• Sinuses• 2 metre conversational voice test each ear
separately
Investigations
• Measurement of the blood pressure (seated)• ECG with computerised interpretation• Audiometry (250 - 8000 Hz)• Urine - protein, blood, glucose• Blood testing – haemoglobin at each medical,
cholesterol (once only at age 40)• Peak Flow Rate, initial Class 1 only unless
clinically indicated• Other investigation as clinically indicated
ECG interpretation
• Computer reading• Certain ‘abnormalities’ accepted as normal• Read rhythm strips not read by computer• Select appropriate computer code NB
different codes for Pilots and for ATCOs• Seek local opinion from cardiologist for
abnormal Class 2 ECGs.• Keep ECG reading skills up-to-date
Disposition• Calculate and include all expiry dates i.e. for
single/double pilot/private pilot(Class 2) Automatic if done ‘on-line’
• Include dates of last ECG and Audiogram• Stamp with appropriate limitations• Issue medical certificate - signed in presence of the
AME by the applicant and witnessed and signed by AME with name under signature
• Remind pilots to read back of their medical certificate which lists extract from regulations and a pilot’s responsibilities
• Defer for further assessment• Deny
Operational Safety Endorsements• 5 OML: Valid only as or with qualified co-pilot
( NB 2 OMLs can now fly together) This endorsement applies to Class 1 pilots. Probably not going to be permitted under EASA rules
• 7 OSL: Valid only with safety pilot and in aircraft with dual controls. This endorsement applies to Class 2 (Private Pilots)
• SSL: Special safety limitations e.g.annual audio• FHA: functional hearing assessment (completed
by training pilot, captain, qualified instructor)
Deferred assessments
• Inform and explain to the pilot the process• Work up case as much as possible• GP/Hospital liaison• Pilot’s consent for information• CAA Algorithms for guidance• Liaison with CAA
Current Validity of JAA medical certificates
• Class 1: 12 months <60: 6 months > 60 for multi-pilot operations
• Class 1: 12 months <40: 6 months > 40 for single-pilot operations
• Class 2 : 60 months < 40• Class 2 : 24 months 40 - 49• Class 2 : 12 months > 50 • NB The 45 days pre expiry date rule• For renewals new date of expiry is anniversary of date
of issue
Validity of European Class 3, UK Class 1 and NPPL certificates
• ATCO: < 40 24 months• ATCO: > 40 12 months• 45 days rule now applies for ATCOs’ as for Pilots• Flight engineers, navigators:12 months• NPPL Initial valid to age 45 then up to 65 years of
age: 60 months. > 65: 12 months
European Class 3 ATCOs and periodicity of ECGs
• Less than 30 48 months• 30 - 39 24 months • 40 and over 12 months
Flight Eng. & Flight Nav. periodicity of ECGs
• < 30 60 months• 30 - 39 24 months• > 40 12 months
European Class 3 ATCOs and periodicity of Audiograms
• < 40 Every 48 months
• > 40 Every 24 months
European Class 3 ATCO’s other clinical requirements
• Comprehensive ophthalmology examination; at initial then refraction within +5 and – 6D: 5 yearly, more than –6D: 2 yearly
• Tonometry; at initial then 40 +: 2 yearly• Haemoglobin estimation under 40: 4 yearly• 40+: 2 yearly• Other tests i.e. Respiratory, CXR, EEG only if
clinically indicated
Flight Engineers & Flight Navigators: periodicity of
Audiograms
• < 40 60 months
• > 40 36 months
Audiometry for JAA Medical Class 1 and 2 Certificates
• Class 1; at initial then under 40, 60 months, 40 and over 24 months
• Class 2; Instrument rating only at initial then under 40: 60 months, 40 and over 24 months
ECG Requirements for JAA Class 1 and 2
• Class 1 initial ( CAA Gatwick)• Class 1 renewal; < 30: 60 months: 30 - 39
24 months: 40 – 59: 12 months: 50 and over 6 months
• Class 2 at initial (all ages): 40 – 49: 24 months: 50 and over 12 months
ECG coding
• Class 1; 55 normal 56 abnormal• Class 2; 70 normal 71 abnormal• European Class 3 (ATCOs) 58 normal 59
abnormal• Only the ECGs coded abnormal are seen by
CAA cardiologists• ECG computer coding diagnosis must
comply with CAA guidelines.
Blood tests• Class 1 Haemoglobin every medical• Class 1 Cholesterol (fasting Lipids) at age 40• European Class 3; Haemoglobin every 4 years under 40 and
every 2 years over 40.• Class 2 Haemoglobin at initial plus any other tests as
clinically indicated. • Class 2 Cholesterol if more than two coronary risk factors
identified at initial (at any age) or if 40 years of age or older for renewal/revalidations.
• Other tests as clinically indicated• No blood tests required for UK Class 1
Pitfalls
• Poor history taking• Hurried examinations• ‘Tickitis’!!• Deniers - pilots want to pass the
examination!• Bogus applicants - NB photo identification• Too low index of suspicion
Administration
• Records/medical files/computer/CAA on-line• Booking appointments• *Forms: application (can be printed from on-line
system), medical, ophthalmic, ENT* only needed for back up if on-line system fails or
for non CAA/JAA applicants i.e. Ireland• Medical Certificates • Renewals/reminders/on-line booking systems• Computerisation/ Web sites/ E-mail
Administration - finance
• Charges• Debit or credit cards/cheques/cash• Accounts – book keeping• Income tax!!• Expenses• VAT
Continuing medical education
• During the period of authorisation (3 years) an AME must complete a minimum of 20 hours refresher training.
• Scientific meetings, AAME, AsMA, ICASM• Flight deck experience/simulator (NB: Post
September 11th problems for flight deck visits)• Revalidation/Annual appraisal (GMC re-licensing
of doctors) N.B. AAME Appraisal service• CAA Annual audit
Appraisal requirements
• Annual appraisal• Mission statement• Complaints policy• Security of records and offices• Customer satisfaction survey (see AAME
website)• Staff training and confidentiality
Suspension/withdrawal of CAA approval
• Suspension by GMC• Failure to participate in CME• Poor record keeping• Poor clinical assessment• Unsatisfactory clinic arrangements• Failure to follow and apply regulations• Informal then written then final warnings
CAA Good Medical Practice Guidelines
• Publication of guidelines document• Annual audit• Appraisal and 5 year GMC re-license• Role of AAME in appraisal• CAA Algorithms (keep in a file)• CAA web-site for updates
CAA Good medical practice for AMEs
• Section 1 Providing good medical practice• Section 2 Maintaining good medical practice• Section 3 Teaching,training,appraising and
supervising• Section 4 Relationships with applicants• Section 5 Working with colleagues• Section 6 Probity and health• Section 7 Practice facilities
Current political issues
• European Aviation Safety Agency (EASA)• European Society of Aerospace Medicine (ESAM)• European Class 3 ATCO medical certificate now
in place• New European Leisure Pilots Licence (LAPL)• Cabin crew medical examinations• Retirement age of Pilots, age discrimination issues• ICAO recommendations Class 1 under 40 years of
age
ICAO
• Frequency of Class 1 medicals for pilots age <40• Seen annually but medical examination every 2
years• Visual check and emphasis on health education
and behavioural issues, depression, drugs, alcohol etc. every alternate year
• Additional physical examination and investigation as clinically required
ICAO recommendations
• Less emphasis on gynaecological issues, i.e. menstruation questions
• Pilot’s obligation to report illness/accident etc. to be based more on the condition and not on the number of days off sick
CAA new developments
• New Colour Assessment Diagnosis (CAD) test• Pilots with Insulin dependent Diabetes• Depression and SSRIs• ? Pilots with positive HIV no longer to be classed
as permanently unfit• Emphasis on early diagnosis and treatment• Certification of pilots on anti retroviral medication• Brughada Syndrome new algorithm
Current medical issues
• Pilots’ fatigue and proposed EASA increase in flying hours limitations. 900 to 1000 hours per annum.
• Security checks at airports• ? Flight deck/cabin air contamination• Cosmic radiation (? Need for monitoring)• Hypoxia awareness and training• Flight deck noise (use of noise attenuating headsets)• Breast cancer and night work• H1N1 virus infection
Other current medical issues
• Possibility of grading periodicity to risk and level of fitness
• Retirement ages and age discrimination• Disability discrimination and the disabled
pilot• Drugs, booze and flying!
The Railways and Transport Safety Act 2003
• Breath alcohol limit 9 mcg/100ml• Blood alcohol limit 20 mcg/100ml• Urine alcohol 27 mgms/100ml• Extends to Flight Deck and Cabin Crew• Engineers limits are 35mcg (breath): 80mcg (blood)
& 107mgms (urine)!!• Powers of police to test and arrest• No random tests. Must be reasonable grounds• Tests following accident
Drugs, Booze and FlyingThe UK CAA role
• Pilot referred to CAA, alcohol questionnaire• Seen and examined• Blood tests, MCV, GGT, Carbohydrate Deficient
Transferrin test (CDT)• Testing of hair for drugs• Treatment, Acamprosate and CBT• AA, Alanon etc.• Rehabilitation not discipline
The Association of Aviation Medical Examiners
• Provides sufficient CPD through Annual Scientific Meeting
• Appraisal and re-validation service• Web-site www.aame.co.uk• Liaison with colleagues and European scene• Free first year membership• Link to UK for overseas members• Non political and not a trade union
The Work of an Authorised Aviation Medical Examiner
•Any Questions?