German wings Crash - Depressed Aircrew

[Jedi Doc]

The recent Germanwings crash has stirred a lot of discussion on several topics:

1. Importance of having more than one person in cockpit at all times

2. Reporting mechanisms for mental and medical health from all sources of medical care

3. How to address depression and mental health disorders in pilots

I have read quite a few blogs and editorials suggesting there is no room for depression or mental health issues in anyone allowed in a cockpit. My personal opinion is that this is the wrong direction to go. There needs to be a way for pilots who are depressed to get back in the cockpit, a pragmatic rational approach is preferred to a 'zero tolerance' one.

See recent blog post: https://goflightmedicine.com/germanwings-depression/

What are your thoughts? Should depressed pilots be allowed to fly or get back in the cockpit under certain conditions?

[busdriver]

Third point in blog post is spot on. Zero tolerance= problem gets hidden.

[Warrior]

Third point in blog post is spot on. Zero tolerance= problem gets hidden.

Came to post this, even before I looked at the article.

[Jedi Doc]

It is not surprising but disappointing how the public does not understand or appreciate this fact. I hope that aviation's regulating bodies are able to resist the pressure to be reactionary and further limit the current processes in place to treat depressed pilots and then return them to the cockpit.

Check out the majority of comments on the previously linked article's FB: https://www.facebook.com/goflightmedicine?ref=tn_tnmn

Please share the article so that some may be aware of the unintended consequences of not giving depressed pilots a path to return to flying.

[waveshaper]

The commercial airlines may need to take a look at possibly incorporating a "FEW" of the Nuclear Surety Protocols for

their pilots/pilot trainees. Any protocols selected would need to be tailored to fit the civilian world, be

significantly more forgiving, and give pilots "with treatable conditions" a path back to flying. On the medical side

of the house the Personnel Reliability Program (PRP) has strict procedures/rules for Physically, Emotionally, and

Psychologically evaluating personnel on a sustained/continuous basis (daily if need be).

The PRP program has strict procedures in place that will identify and "immediately" remove folks from certified PRP

positions/status/all related duties by; Suspension (up to 30 days), Temporary Decertification (up to 180), and Permanent Decertification. This pilot wouldn't have lasted 10 minutes in the PRP world (my opinion) and most likely wouldn't meet

the minimum requirements to even be initially administratively certified let alone formally certified into a Critical

Position or any other PRP position for that matter.

It also may be wise to look at the Two-Person Team concept and Critical Position certification/classification to see if

there's anything in these protocols that could be used to improve commercial airline security/safety (particularly in the

cockpit).

I know, stupid idea/not my lane but it's Friday; Fire away.

[jcj]

I'm a general surgeon, civilian pilot and former navy corpsman - I was in OKC at the FAA Civil Aerospace Medical Institute (CAMI) in the AME basic course when this went down. Obviously it initiated a lot of discussion while we were there - although many of the details we now know came out after we left for home.

My thoughts are this: About a year ago (of course before the Germanwings incident) the FAA did a study of pilot-aircraft suicide. It does happen, but it is extremely rare in U.S. aviation (see link below for details).

The full-time FAA docs (almost all of which are retired military or NASA flight surgeons and are BC in aerospace medicine) "get it" that it's safer to have a pathway for certification for pilots with mild/moderate depression on SSRI's than an absolute prohibition which results in the problem being hidden - which most know was the case until recently. They "get it" that the current process is cumbersome and interrupts medical certification for at least 6 months, and finding a HIMS AME is sometimes not an easy task (for example there isn't one in Arkansas at all - there is one in Memphis who is the closest). And they also "get it" I think that the Germanwings incident was an anomaly that it would be difficult - if not impossible - to effectively screen for and would be better prevented by operational measures rather than tightening aeromedical standards.

I think the FAA docs would very much like to find a way to simplify the depression/SSRI med program. But they live in a very political system and will have their hands full fending off proposed "solutions" to the Germanwings incident based on political expedience rather than sound aeromedical logic. I think they will be effective in preventing any unwarranted changes to the current system, but I'm guessing the political fallout will prevent any significant progress in improving (read: simplifying) the current process for a while.

Here is a nice read in the MSM (now several days old but still a good read) about why enhanced aeromedical screening probably isn't a reasonable way to prevent another incident: https://www.nbcnews.com/storyline/german-plane-crash/could-better-screening-catch-suicidal-pilots-n331406

Edited April 7, 2015 by jcj

[JarheadBoom]

I'm a general surgeon, civilian pilot and former navy corpsman - I was in OKC at the FAA Civil Aerospace Medical Institute (CAMI) in the AME basic course when this went down.

Slight derail from the Germanwings discussion, but relevant (I think) to the bigger-picture discussion WRT FAA medical screening and voluntary disclosure of "attention-grabbing" medical issues:

Given your recent presence with the FAA docs at OKC, what's your take on the recent dust-up re: overweight pilots and sleep apnea screening?

If these guys, as you say, "get it" that more cumbersome rules/processes aren't necessarily the best answer, what the hell happened with the sleep apnea thing?

[dvlax40]

Deny till you die....

seriously how many pilots die each year of things that could have been fixed if they were reported sooner (some times YEARS sooner)

Another problem is the Healthcare industry. there is a difference between being sad from a divorce and being "clinically dperess" but the DSMs are written so ambiguously that they can be interpreted in such a broad way. what happens is the dude thats sad his wife left him, goes to a therapist to talk through it is labeled as "clinically depressed" because the insurance company requires an ICD code and diagnosis to pay out on the visit.

see why people dont want to get help. because in most cases where just talking to someone would be enough, our healthcare industry REQUIRES the doctors to label them

[jcj]

Slight derail from the Germanwings discussion, but relevant (I think) to the bigger-picture discussion WRT FAA medical screening and voluntary disclosure of "attention-grabbing" medical issues:

Given your recent presence with the FAA docs at OKC, what's your take on the recent dust-up re: overweight pilots and sleep apnea screening?

If these guys, as you say, "get it" that more cumbersome rules/processes aren't necessarily the best answer, what the hell happened with the sleep apnea thing?

It was also a major area of discussion.

Short answer is that the prior, oversimplified "everybody with BMI of 40 or more gets a sleep study" was replaced with a more complex, but I think more appropriate screening process based on criteria of the recognized medical experts in the area - the American Academy of Sleep Medicine (AASM) (https://www.aasmnet.org) - this makes sense to me because there are people with BMI of > 40 who don't have obstructive sleep apnea (OSA) and some with much lower BMI's who do. And untreated severe OSA really is an aeromedical safety issue.

The current (as of today) guidance is here: https://www.faa.gov/about/office_org/headquarters_offices/avs/offices/aam/ame/guide/dec_cons/disease_prot/osa/

Longer answer: Every applicant for every class of medical is screened and ends up in one of six categories by a flow chart (contained as a pdf reference in the link above). We are required to document this in the exam portion of the system for all applicants. Here's my brief summary (for the definitive info see the FAA documentation) - you will end up in one of the six categories below:

1. If you already have a special issuance (SI) certificate for OSA you'll stay in that category. In most cases if your OSA treatment is satisfactory and you're otherwise qualified, your AME will be able to issue your follow-up certificates through the AASI process (the first SI certificate must still come from OKC). If you have permanent treatment (i.e. substantial weight loss or UP3) that rids you of OSA there's a way to get out of this but it's complicated.

2. If you've already been diagnosed by your doctor with OSA and are being treated (and haven't yet reported it to the FAA), but you're otherwise qualified - you'll need to report it on MedExpress. If otherwise qualified you'll receive a certificate from the AME. But the FAA will write you and want documentation on their Spec sheet "A" (see link) which means data from the recording function of your CPAP machine. They want 6 hours use per night, and they understand and are willing to accommodate those with irregular schedules such as commercial pilots with irregular overnight schedules who may travel with a portable non-recording machine.

3. If you don't have 1 or 2 and you have no risks for OSA (not obese, no large neck size, no daytime drowsiness) the AME just marks that on the record that there's no risk for OSA and that's all.

4. If you have some risk factors for OSA but not at severe risk, the AME will issue your certificate if you're otherwise qualified and educate you about OSA (it's a real thing with significant consequences). The risk factors are those developed by the AASM - references available on the FAA link. Nothing else happens and your certificate is good for whatever duration it's otherwise good for.

5. If you have severe risk factors for OSA but don't seem to present an immediate flight danger, you'll be issued your certificate by the AME if otherwise qualified but you'll get a letter from the FAA wanting an evaluation within 90 days (see Spec sheet B in the reference) - this does not necessarily require a sleep medicine specialist or a formal sleep study - your personal physician can do it if he/she feels qualified. But they must follow AASM guidelines (again doesn't necessarily require a formal sleep study)

6. High risk for OSA that, in our judgment is in immediate aeromedical safety risk. - this is the only category where we are told to defer the application to the FAA rather than issue with required follow-up. Examples given to us are - the airman has multiple OSA risk factors and is found asleep in your waiting room waiting to be called back for exam or falls asleep during the exam (without an acceptable explanation such as being up all night at work the night before the exam). ***THIS IS THE ONLY APPLICANT WHO WILL NOT LEAVE THE AME OFFICE WITH A CERTIFICATE BASED ON OSA ISSUES***

However if you have a certificate issued by the AME and the FAA sends you a letter requesting additional info and you don't provide it, your certificate is voided.

It's complicated, but I think makes a lot of sense and is much better than the first (now rescinded) version of "everybody with BMI>= 40 gets a sleep study" In fact, we're not allowed to use BMI as the sole criteria for any of these decisions we are required to use the AASM criteria (of which BMI is one).

One last thing - OSA is a real disease with real, sometimes fatal consequences. Patients with BMI >= 40 have a 90% probability of having significant OSA. It;s something to think about for your health in general, not just your fitness to fly.

For those interested, the most current guidance for AME's is always available (to the public as well as AME's) at : https://www.faa.gov/about/office_org/headquarters_offices/avs/offices/aam/ame/guide/. We are encouraged to always consult the latest internet version, rather than any paper versions we may have since the official version (always the one on the internet) may change sometimes several times in a month. There's also a lot of good information about the AME process - including the OSA issue with videos - at https://www.faa.gov/go/ame

(sorry for multiple edits but this is both important and high profile so I wanted to be sure I had it right)

Edited April 8, 2015 by jcj

[jcj]

Deny till you die....

seriously how many pilots die each year of things that could have been fixed if they were reported sooner (some times YEARS sooner)

Another problem is the Healthcare industry. there is a difference between being sad from a divorce and being "clinically dperess" but the DSMs are written so ambiguously that they can be interpreted in such a broad way. what happens is the dude thats sad his wife left him, goes to a therapist to talk through it is labeled as "clinically depressed" because the insurance company requires an ICD code and diagnosis to pay out on the visit.

see why people dont want to get help. because in most cases where just talking to someone would be enough, our healthcare industry REQUIRES the doctors to label them

Agree with your concerns - the situation is very imperfect. There is a diagnosis (dysthymia) that is basically an appropriately sad or somber mood, situationally appropriate because of events such as a divorce. there will be more when we go to ICD - 10. Sometimes one has to be proactive with one's provider to get them to document that diagnosis since it's so easy to just diagnose "depression" and move on. not defending this approach at all - just describing it so interested people will know and can take countermeasures. However diagnoses and coding of diagnoses are so embedded in the framework of health care - they aren't going away.

[JarheadBoom]

It was also a major area of discussion.

<words>

Wow... Thanks for putting the time into a detailed answer; I appreciate it.

[deaddebate]

https://www.asma.org/asma/media/AsMA/pdf-policy/2015/AsMA-Pilot-Mental-Health-Working-Group-Recommendations-September-2015.pdf

Read pages 4 and 6-10

 

Edited November 2, 2015 by deaddebate