Dave Unwin’s PTT
Mental fitness to fly?
Now, you might imagine that the tragic crash of the Germanwings A320 on 24 March would be unlikely to affect the sport aviator, but you’d be wrong. Indeed, industry watchers have always been keenly aware that there is an ever-present danger of recreational aviation being adversely affected by inadequately thought-through, watereddown legislation initially intended for Commercial Air Transport. We’re all aware of EASA’S propensity during the first decade of the 21st Century to promulgate regulations that — although designed for commercial airlines — eventually affect every little flying club.
During the recent International Congress of Aviation & Space Medicine, held in Oxford, one hot topic was the mental health of pilots and — as you may imagine — views were polarised on the subject. For many years some psychologists have argued that they should assess pilots as well as AMES, and in the wake of the crash the European Federation of Psychologists’ Association (EFPA) issued a statement saying ‘Psychological assessment before entry to flight training and before admission to active service by an airline can help to select pilots.’ However, the federation stressed that ‘it could not forecast the life events and mental health problems occurring in the life of each individual pilot, nor could it predict the unique way a pilot would cope with these.’
Call me cynical, but I can forecast that legislation requiring pilots to have psychological testing would certainly generate work for psychologists, and predict this would favourably affect their incomes!
Anyway, in a typical knee-jerk reaction some delegates argued that the way forward was for regular, rigorous psychological testing of flight crew, coupled with the immediate suspension of the licence of any pilot suspected of mental illness. More enlightened AMES proposed that better support and additional help for sick pilots would be more productive, and this view was supported by a paper from the Royal Air Force. Having thought about it, I couldn’t help but wonder whether increased involvement by specialists (such as psychologists) could actually be counterproductive. Indeed, the tragic crash of Germanwings flight 9525 clearly revealed a fundamental flaw in the premise of the aviation medical, for the man who crashed the aircraft, first officer Andreas Lubitz, held a valid medical certificate. However, unbeknown by his employers, Lubitz had been treated for depression and ‘suicidal tendencies’ and had been declared ‘unfit for work’ by a doctor. A search of his apartment revealed that he was taking prescription drugs for his mental illness, and while he’d successfully hidden this fact from his AME (probably by simply lying), he had sought help from many other doctors and been prescribed various drugs, although no doctor had properly addressed his underlying mental illness.
Patient/doctor confidentiality ensured that Germanwings was not informed about his condition, and quite rightly under German law, as here, employers do not have access to the medical records of employees. In fact, even a ‘sick note’ excusing a person from work does not provide any information on an employee’s medical condition — it simply states that they are unable to work. There have been rumblings in the German mass media that this law needs changing, and I asked an old friend, a retired senior RAF medical officer and the British Gliding Association’s Medical Advisor for more years than he probably wants to admit, about this issue. His observations were, as always, both shrewd and illuminating. He told me he had calculated that he receives a psychiatric referral at the rate of one per 1,770 member/years — which is very low. In fact, with such a low incidence, false positives from psychological screening, even at a one per cent rate, would greatly outnumber the true positives, the process creating more problems than it would solve!
A concerned employer should interview any employee after return from sickness absence, and in a large airline this should be the task of the medical department. And, rather than resorting to more regulations, EASA would do better to learn from the BGA and the RAF, by implementing pilot support systems.
The BGA limits a pilot to a named club, ensuring that responsible officials at that club are aware in confidence of the problem and provide support whilst ensuring safe operations. This is clearly a better solution because, irrespective of whether someone flies for fun or for a living, if they’re depressed, do you really think that grounding them is going to cheer them up? Of course not! Recently a BGA member, who had recovered from a depression, told his club that if it had not been for their support, he would have killed himself!
As with most health problems, the initial step to treatment is to know about it in the first place. The first people to realise that there is a problem are typically family, friends and colleagues, the next to know being the GP. To inform a doctor, there has to be trust by the informant that the patient will be managed with fairness. Once diagnosis has been established it can usually (but not always) be treated. However, if a doctor has — by law — to inform regulatory authorities, then pilots will be even less likely to seek treatment in the first place.
Legislation obliging doctors to inform authorities never works, not just for ethical reasons but because sick patients then shun necessary treatment. Whether in the past for homosexuals in the armed services, or currently for the heinous crime of female genital mutilation, doctors know that patients will not come forward for treatment if bad consequences were to follow. Some members of the aeromedical community have forgotten that as physicians their duty is to support pilots, not just to act as a police enforcing regulations. Perhaps they should remember Hippocrates, who not only taught that doctors should respect confidences but to “cure sometimes, treat often, comfort always”. And he didn’t say anything about policing.
False positives from screening would outnumber true positives