Dave Unwin’s PTT

Men­tal fit­ness to fly?

Pilot - - CONTENTS - DAVE UNWIN Pi­lot’s Flight Test Editor operates a Jodel D.9 from a farm strip and has logged stick-time on every­thing from ul­tra­lights to fast jets

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

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