Welcome to The Flight Shrink newsletter! This is Dr. Kevin Heacock.
There have been some big announcements in the last few weeks related to mental health and aviation safety. The first was the announcement by the National Transportation Safety Board (NTSB) that they would hold a roundtable to discuss pilot mental health. The agenda on their website shows they will have a panel of first person accounts to the FAA’s approach to mental health followed by a panel of views from the FAA, providers, and researchers about the current approach to evaluating mental illness.
I notice here that they plan to have providers. I think that’s great. I just hope the providers they have are mental health providers like psychiatrists and psychologists. It is great that mental health is important to everyone and all providers should be empowered to treat patients with mental health concerns. But in my 18 years as a physician and 10 years as a psychiatrist I can’t tell you how many times I’ve heard other doctors say how thankful they are that they don’t have to see mental health patients exclusively.
Sure, primary care doctors and specialists like dermatologists, neurologists, and even surgeons have to think about the mental health of their patients and offer first line treatments. But when it comes to managing patients with mental health concerns or thinking about the implications of these disorders in highly visible and important populations such as pilots, it really should be psychiatrists and psychologists who have years of training in this area of medicine as well as extensive experience treating these patients that are called upon to assess the situation.
Hopefully, this NTSB roundtable brings together mental health experts like this along with aeromedical experts, expert pilots, and experts in understanding how the aviation industry works so we can keep pilots mentally healthy and get them the care they need when their mental health suffers a set back, all while keeping the skies safe for other pilots and travelers.
I’ll be attending this NTSB roundtable on 6 Dec in Washington DC, so if you’re going too, please say hi. It’s always great getting to interact with readers and listeners in person.
The other big news related to aviation mental health was the FAA's announcement that they will be forming a Pilot Mental Health Aviation Rulemaking Committee (ARC) that will develop strategies to encourage pilots to report mental health issues. It will include medical experts and representatives from aviation and labor and they will draft recommendations for the FAA. A similar ARC was formed in 2015 following a Germanwings crash that was ruled a suicide as the co-pilot deliberately caused the plane to fly into the French Alps killing all 144 passengers and 6 crew. That ARC made recommendations related to AME Training, Psychological Testing, Pilot Assistance Programs, and Air Carrier Education among others. Other than requiring two crew on the flight deck at all times it’s not clear to me what other changes to aviation practices were made.
With the NTSB roundtable next week and the results of the FAA ARC coming next year, I thought I would put on my flight surgeon hat and try to discuss one of the considerations that will need to be kept in mind when discussing changes to aviation standards. And that is Aeromedical Risk.
I have been a flight surgeon since 2006 and have spent most of my career treating and evaluating pilots and assessing their aeromedical risk. When I thought it wasn’t safe for someone to fly I would have to disqualify them from flying. And luckily, after treating them, I was able to return most of them to flying. So understanding aeromedical risk is something I have a lot of experience in. As I discuss it here, I’d like to note that these are my views and they do not reflect the official policy or position of the Department of Defense, The United States Air Force, or any other organization I am associated with.
With that said, let’s see if I can help you understand aeromedical risk a bit better.
Pilots probably understand a lot of the risks involved with flying when it comes to the mechanical function of aircraft as well as training standards for pilots. If parts on the plane are not functioning properly, they are unsafe to fly. If a pilot has not had the proper training, whether that be flying in general or aircraft specific, then they are unsafe to fly.
Some level of risk IS accepted though. If a part is not likely to fail or if it does fail and it’s function is not critical to flight then you can accept that level of risk. If a pilot has not had all the training needed then they are more likely to fail and this would be critical to the success of the flight and so you would not accept that risk. But if that pilot is flying with another qualified pilot, then the likelihood of a critical event occurring has been reduced, and then you can accept that risk.
What pilots may not understand as well is medical risk. But medical risk is really thought of the same way. If a pilot has a medical condition that could lead to a critical event that would cause injury or death to the pilot or anyone else, then the risk is too high.
So what you really need to know are two things:
how likely is it for a medical condition to occur and
what level of risk are you willing to accept.
Knowing how likely a medical condition is to occur can be found in medical research papers on each condition. It’s important to remember these papers find an average or a range of likelihood in the population of people studied. But not everyone is the same and not everyone has had the same care or treatment. So while we may know what the literature says when it comes to the likelihood of someone having a heart attack, the person needs to be interviewed and evaluated to really understand that individual’s likelihood to have a certain medical event.
Knowing what level of risk to accept is something that has to be agreed upon by all the stakeholders. In the U.S. the FAA draws the line with how much risk to accept. While not explicitly stated in FAA guidelines they generally follow the internationally accepted threshold for risk. The level of aeromedical risk that is accepted internationally is known as The 1% Rule.
The math behind The 1% Rule is pretty complicated (meaning I don’t quite understand it). But for the most part, what it means is that if there is a 1% chance that within the next year a pilot could have a medical condition that would lead to a catastrophic failure of a flight, the risk is too high to allow that pilot to fly.
An example is, say you are a pilot at home and you have a seizure. You go to the doctor and the doctor says, your risk of having another seizure in the next year is 36%. In people like you who have had one seizure, 1 out of 3 of you will have another seizure in the next year. Well, that’s well above the 1% rule and it’s probably why people who have had a seizure not only can’t fly, they’re not allowed to drive and are told to not swim alone, cook with fire, or hang out at height.
But you might be thinking, I feel fine. I’m not seizing right now, why can’t I drive or fly? You have to remember that, when it comes to aeromedical risk, it’s not how you’re functioning right now that matters, it’s what is the risk of disfunction occurring in the future, when you’re flying.
This makes sense if you think about it from one of the other areas of aviation safety, mechanical risk. If you just flew a plane and landed without any problems, and while you’re refueling for the next leg of your trip maintenance comes over and says, hey, we just checked out your engine and there’s a 33% chance that engine is going to fail in the next year. I’ve seen thousands of engines like this before and 1 out of 3 of them fails in the next year. Do you still want fly? Sure, the plane just performed perfectly, but I’m pretty sure no pilot would take that risk.
So yea, a 30% risk is too high to accept. And some people think setting the aeromedical risk at 1% is too low. What do you think? If there was a 1% chance of your engine failing in the next year, would you fly that plane? Perhaps you would. I’ve seen at least one paper say that the accepted risk for engine failure in a twin engine aircraft is about 5-6%.
So if the 1% rule is too low and 30% is too high, what’s an acceptable level of risk? As you might imagine, different people may be willing to take different levels of risk. Some people sky dive and some don’t. Some people free climb mountains and other people use ropes. But when it comes to flying passengers around or flying over people’s houses, it’s probably best we all come to a consensus on the risk we’re going to accept. Because even if we’re flying solo, a mishap could affect more than just the pilot.
One solution that has been proposed is varying the level of risk accepted based on the severity of the outcome should the medical event occur. So sure, if a pilot had a migraine headache in flight it could cause a catastrophe, so we wouldn’t accept more than a 1% risk of that happening. But if the pilot has 3 or 4 stress headaches a year that resolve with over-the-counter ibuprofen, even if they get a headache in flight it probably wouldn’t have a critical impact. So we might accept even a 50/50 risk of them having another headache in the next year.
This way of thinking about aeromedical risk has become known as a Risk Matrix. I will discuss this in next week’s flight along with a way to think about aeromedical risk of mental health conditions through this lens.
If you made it this far through the newsletter or podcast, thanks for sticking with me as I try to explain some pretty technical stuff. But most of you are probably pilots, so you probably like technical stuff. And I hope you liked this one. If so, please like and share. And…
Keep on flyin’!
Seeking Aeromedical Guidance
The Flight Shrink newsletter and podcast is an extension of my civilian aerospace psychiatry consultation practice. I’m certified by the FAA as an AME and as a HIMS Psychiatrist. So I would be happy to consult with you confidentially on any mental health related aeromedical questions. Other services like this on the internet charge as much as $90 per question. So for my newsletter subscribers and podcast listeners I figure you deserve at least 50% off that. And so, if you have a mental health related aeromedical question you’d like me to address confidentially, just email me at kevinheacockmd@flightshrink.com and for just $45 I’ll address your question.
It can be about any mental health related questions you need help with. Whether that be questions about a mental health condition and how it might affect your medical certificate, how antidepressants might impact your career, or what evaluations the FAA will want if you’re trying to get a special issuance for your mental health condition. Whatever it is, email me at kevinheacockmd@flightshrink.com and for just $45 you’ll get your answer from an FAA certified AME and HIMS Psychiatrist with over 17 years of aeromedical experience.
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Let's soar to new heights while prioritizing our mental health.
I love hearing from readers and listeners, so feel free to Email me at kevinheacockmd@flightshrink.com. Also, you can connect with me on Instagram, X (formally Twitter), Facebook, and Threads with the handle @flightshrink. I have also been more active on LinkedIn recently and you can find me there as Kevin Heacock. And feel free to visit The Flight Shrink substack for archived posts covering a wide range of mental health topics.
Until next time...
I'm Dr. Kevin Heacock, The Flight Shrink... Keep on flyin'!
This is interesting, Kevin- I stumbled upon your profile and for some reason was surprised. Never thought there was such a thing as flight surgeons. But once I think about it, of course!