European Heart Journal (1992) 13, {Supplement H), 21-26
Cardiological aspects of aviation safety — the new European perspective M.JOY
Civil A nation Authority, Medical Division, A viation House, Gatwick A irport South, W. Sussex RH6 0 YR KEY WORDS: Aviation, aircrew licensing, Europe, safety.
Medical standards in aviation Following the armistice in 1919, the League of Nations created the International Commission of Air Navigation which made recommendations to member states and included, inter alia, medical fitness requirements for the issuance of flying licenses. In the United Kingdom, the responsibility fell to the Air Ministry (MA2 division) and similarly in other countries, military authorities were the responsible agencies. The convention on International Civil Aviation was signed in Chicago on 7 December 1944 and included a number of articles calling for the adoption of international regulations to aid uniformity in air navigation. In 1947, the International Civil Aviation Organisation (ICAO) was founded and charged with implementing the provisions of the Chicago convention. It promulgated a series of regulations known as Standards and Recommended Practices (SARPs) which appeared as annexes to the convention, each annex dealing with a specific aspect of civil aviation. Correspondence: M. Joy, Civil Aviation Authority, Medical Division, Aviation House, Gatwick Airport South, W. Sussex RH6 OYR. 0195-668X/92/0H0O21 + 06 S08.00/0
Aviation medicine is primarily dealt with in Annex 1 (personnel licensing)131 but also referred to in Annex 2 (rules of the air) and Annex 6 (operation of aircraft). All nations are signatories to ICAO and bound thereby by international treaty to maintain (or enhance) the standards laid down. In the event of impossibility of compliance, notification to the Council of ICAO is compulsory under article 38. In 1970, the Personnel/Training/Medical (PEL/TRG/ MED) Divisional Meeting concluded that there was a need for suitable guidance material to assist the application of the SARPs, including those in Annex 1. Following the recommendation of the technical body of ICAO (the Air Navigation Commission), a medical study group was set up to prepare suitable material and in 1974, the ICAO Manual of Civil Aviation Medicine was published'41. In 1980, the Medical Director General of ICAO convened a cardiovascular study group meeting to review theexistingstandards and guidance material incardiology. The chapter on the cardiovascular system was re-written and a second edition of the manual was subsequently published in 1985'51
Cardiovascular standards in aviation The statements with regard to cardiovascular health in the ICAO annex are necessarily general statements (see Table 1 )'31 and although individual states may not require a lower standard than those laid down by ICAO, it is possible under Annex 1.2.4.8. for fitness requirements to be waived in special circumstances where the applicant's failure to meet any requirements . . . 'is such that exercise of the privileges of the licence applied for is not likely to jeopardize flight safety''351. In effect, many nations have used this rule to develop theijasic ICAO SARPs with particular application to cardiology in its role as the major cause of professional aircrew licence loss in the Western World'61. The first symposium to consider in detail the problems of cardiology in aviation took place in 1959171. In 1966, the American College of Cardiology recommended that resting electrocardiography should form part of the routine assessment of aircrew181 and the same College, later on in a more comprehensive review of the subject, recommended exercise electrocardiography should form part of the routine scrutiny of aircrew19'. This recommendation was not accepted by any licensing authority, and in any event, the recommendation has been displaced by ICAO requirements with regard to aircrew training for the eventuality I 1992 Tbe European Society of Cardiology
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Introduction When we arose in the morning of the 17 (December 1903) the puddles of water . . . were covered with ice. The wind had a velocity of 22-27 mph . . . . The course of the flight was extremely erratic . . . . This flight lasted only 12 s, but nevertheless was the first in the history of the world in which a machine carrying a man raised itself by its own power... [1l This shaky beginning at Kill Devil Hill, North Carolina saw the birth of powered flight although it was to be another 5 years before the first passenger was carried, by the same pilot over a distance of 2-5 miles in just under 4 min. Seventy years later, the Anglo-French Concorde was carrying 100 passengers across the North Atlantic Ocean. At twice the speed of sound it was exceeding the velocity of a rifle bullet and the capability of the majority of fighter aircraft belonging to the world's air forces. Aircraft development has been given substantial impetus by the conflicts of the 20th Century and early in the history of (military) aviation it was recognised that there was a need for standards of medical fitness for aircrew121. Pilots during the First World War were required to undergo 'strenuous physical examination' in which special attention was paid to vision and the organs of equilibrium. Those showing 'marked nervous tendency' were turned downpl
22 M. Joy
Table V"
The ICA O cardio vascular standards
of incapacitation on the flight deck'3', and, a better understanding of probability analysis'101. In the United Kingdom, the Royal College of Physicians set up a working party which considered the problem over a 3-year period, eventually publishing its recommendations in 19781'". The first U.K. workshop
Many of the statements made in these various reports were empirical and based on what cardiologists felt was appropriate, often without having any detailed knowledge or understanding of the inherent risk and safeguards in civil aviation. In order to improve on what was often an uneven and potentially unfair approach to the problems of cardiological certification, the First United Kingdom Workshop in Aviation Cardiology was convened in July 1982'121. The origins of this workshop to some extent stemmed from the Medical Advisory Panel to the U.K. Civil Aviation Authority, which had been set up in 1977. During the meetings of this Panel, it had become evident that there was a need to bring together the available data on natural history, incidence of complications, and the impact of intervention of a number of the more common conditions in order to define cardiovascular fitness to fly with greater precision'131. The workshop ran over 3 days, working sessions in which each included a moderator and between five and eight discussants. All participants were required to precirculate their material, these submissions forming the basis of the proceedings of the workshop, which was subsequently published as a supplement to the European
The second U.K. workshop
The approach of the First Workshop was developed in the Second'151. The format was the same and an additional section was added on risk seen from the point of view of an epidemiologist''61 a licensing agency1'7'81 and an actuary1'91. Chaplin'171 indicated that no transportation system was free from risk and the controlling legislation did not require it to be so. It had to be 'safe enough'. It was also indicated'17'181 that in multi-crew operations (where crew training for the possibility of incapacitation is mandatory) the target fatal accident rate was one event in 107 flying hours'6-181. Furthermore, medical cause accidents should not form more than 1 % of the total accident experience, implying that medical cause accidents to multi-crew aircraft should not exceed one event in 108— 109flyinghours. In the past 5 years, the fatal accident rate has remained at about one event in every 6 x 105 flying hours'21', while a cardiological cause accident rate is probably better than one event in 2-5 x 108flyinghours'6181. Similarly, in a single crew operation in which the fatal accident rate is likely to equal the serious incapacitation rate, and in which the observed accident rate is of the order of one event in 105flyinghours, by extrapolation the objective for medical cause accidents should not exceed one event in 107 flying hours. This coincides with the annual cardiovascular mortality rate in U.K. males aged 45 years or less'221. Observational data suggests that this target is being achieved. The 1 % rule and professional aircrew licensing
The targets outlined above have been developed into what has become known as the' 1 % rule1'221. This rule may be defined as the predicted annual medical (cardiological) event rate which, if exceeded, should excludea professional airman from flying a multi-crew aircraft. A 1% risk of
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6.3.2.5 The applicant shall not possess any abnormality of the heart, congenital or acquired, which is likely to interfere with the safe exercise of the applicant's licence and rating privileges. A history of proven myocardial infarction shall be disqualifying. Note. — Such commonly occurring conditions as respiratory arrhythmia, occasional extrasyswles which diasppear on exercise, increase of pulse rate from excitement or exercise, or a slow pulse not associated with auriculo-ventricular dissociation may be regarded as being within 'normal' limits. 6.3.2.5.1 Electrocardiography shall form part of the heart examination for the first issue of a licence and shall be included in reexaminations of applicants between the ages of 30 and 40 no less frequently than every two years, and thereafter no less frequently than annually. Note I. — The purpose of routine electrocardiography is case finding. It does not provide sufficient evidence to justify disqualification without further thorough cardiovascular investigation. Note 2. — Guidance on resting and exercise electrocardiography is published in the ICAO Manual of Civil Aviation Medicine (Doc 8984-AN 1895). 6.3.2.6 The systolic and diastolic blood pressure shall be within normal limits. Note I. — The use of drugs for control of high blood pressure is disqualifying, except for those drugs the use of which, according to accredited medical conclusion, is compatible with the safe exercise of the applicant's licence and rating privileges. Note 2. — Extensive guidance on the subject is published in the ICAO Manual of Civil Aviation Medicine (Doc 8984-AN1895) 6.3.2.7 There shall be no significant functional or structural abnormality of the circulatory tree.
Heart Journal^. Section headings included Hypertension and Biochemical Risk Factors, Coronary Artery Disease, Arrhythmias and Electrophysiology, and Valvular Heart Disease, Congenital Heart Disease and Cardiomyopathy. Emphasis was placed on epidemiology, and participants were chosen for their special expertise in the cardiological aspects of the subjects chosen for review. Initial briefing of the aviation operational environment was given at the American Airline simulator complex at Gatwick. Tunstall-Pedoe"41 made a significant contribution by suggesting that (cardiovascular) event rates could be expressed in the same units as aircraft accident rates, commonly events/million h. This emphasized the position of the airman as one component in an operational loop in which any one of the individual constituent parts could fail. Likewise in engineering terms, there are target event rates with the objective of maintaining the probability of catastophic failure at or below a predetermined minimum level. He also drew attention to the highly age- and sexdependent relationship of cardiovascular risk and the relative lack of efficacy of special screening tests on the overall population event rate.
Cardiological aspects ofaviation safety 23
Table 2
UK CAA medical advisory panel decisions 1984-1991 inclusive Licence I
2
II
IIR
III
8t 2
8t
IIIR
U
Total
7 2 6
6 6* 4
30 12 18 1 1 1 3 3 5
1 1 1
4
2 1
3
2 6
1 3 1 1
1 1 4 1
2 7 3 5 2
2 1
2
1 3
15
53
5 11 6 12 3
i
i
l
l
1
1 2 6 I 137
6 1 15
6 9
1
32
(f)oneand (*)two of these subjects underwent coronary angioplasty (i.e. fourin all). Licence types, I: air transpo rt of passengers and air traffic controllers (ATCO), II: airwork (crop-spraying, instruction); III: private. The suffix R denotes a restriction i.e. to multicrew operations (Oass I) or to carry a safety pilot (Class III). U: unfit any category.
event per annum corresponds with one event per 100 years or approximately one event per 106 h. It is the cardiovascular mortality rate of a male aged 60-65 in the U.K.'221 and is based on the assumption that 10% of the flight may be 'critical' (i.e. take-off, climb out, descent, approach, landing) and that in 1% of events occurring during this critical period, the mission may not be retrievable1'81. With a cardiovascular event rate of one in 106 hours, it should be possible to achieve a medical cause accident rate in multi-crew operations in line with the stated target — one accident in every 108 flying hours. Such a generous target should not be acceptable for single-crew commercial operations and any pilot approaching this predicted event rate should be required to have his licence endorsed to fly 'as or with co-pilot' under ICAO annex 1.2.4.Sfc)13'. The evolution of these targets requires the cardiologist to indicate only the likely event rates in an individual and not to make an empirical judgment with regard to the certificability or otherwise of a given airman. The ' 1 % rule' has proved both practical and workable over a number of years in the U.K. in its application to professional aircrew certification. It necessarily makes certain assumptions and it should be noted that the operational environment has changed somewhat. Orginally long haul, transoceanic flights all used aircraft carrying three crew, (two pilots and a flight engineer) whereas 'short haul' operations increasingly employed two pilots only. With increased automation and better standards of
reliability, two-crew aircraft now fly the world on long haul operations without always the need for a backup crew. Whether the ' 1 % rule' is as applicable to these operations needs debate as the pressure on the performance of a remaining crew member under the circumstances of incapacitation of his/her colleague is likely to be significant.
The medical standards for private pilots (JAA Class II) also bear consideration. In the U.K. and in other countries, the fatal accident rate in this group approximates 1 in every 40 000 h flown'23', this being 10-20 times worse than the prevailing scheduled airline accident rate'24'. As the majority of operations flown by private pilots are single crew, total incapacitation of the pilot in command will almost inevitably lead to an accident. If it is proposed that not more than 1 in 25-50 of all fatal accidents to private aircraft should be due to medical cause (cf above: 1 in 100 for Class I operations), then the cut-off point for Class II certificate holders may also be drawn when the predicted cardiovascular event rate exceeds 1 in 1 million flying hours, or, approximately 1 % per annum. Such a target has the advantage that it is concordant with that for Class I holders with licences endorsed to fly 'as or with co-pilot' and consistent with the observed medical incapacitation fatal accident rate in the largest data set
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Myocardial infarction Coronary artery disease Coronary artery bypass grafting Muscle bridge Athletes heart Myocarditis Aortic valve disease Aortic valve replacement AV conduction anomaly Hypertrophic/Dilated cardiomyopathy Left bundle branch block Wolfe-Parkinson-White syndrome VPB/VTach Sinoatrial DIS/SVT Atrial fibrillation Peripheral vascular disease AV malformation Heart transplant Hypertension Pacemaker Congenital (fallot) Total
IR
24 M. Joy
Table 3 1991
FAA special issuances of medical certificates as of 1 July
Priority list description Coronary artery bypass surgery Myocardial infarction Coronary artery/heart disease Aortic valve replacement Mitral valve replacement Implanted pacemaker Carotid artery disease Angioplasty
First class
Second class
106 108 73 15 2 1 23 1
179 114 81 23 7 5 37 5
available1251. It would be difficult to define an acceptable standard based on such principles to permit restricted certification of Class II certificate holders with lesser standards of fitness.
As part of the ongoing European Harmonization Process'261, it was proposed that there should be mutual recognition of licences for aviation personnel and this implied a common medical standard for the aircrew of member nations. The European Civil Aviation Conference (ECAC) was tasked jointly by the EEC and ICAO to evolve the Joint Airworthiness Authorities (now the Joint Aviation Authorities) which is to have responsibility for the regulation of all aspects of aviation in Europe. A number of subgroups, including a Flight Crew Licensing (FCL) Medical Subgroup, were detailed to write a comprehensive medical standard based on an interpretation ofthelCAOSARPs. Various Drafting Groups were set up by the FCL Medical Subgroup, one of which examines certificatory standards in cardiology. This group was chaired initially by the United Kingdom (later by Denmark) and attended by representatives of Denmark, Finland, Ireland, France the Netherlands and Portugal. The recommended standards and their associated appendices were accepted by the FCL Medical Subgroup in the Summer of 1992 (see Annex I). Guidance material interpreting the standards was written by the United Kingdom and accepted at the same time. These standards, their associated appendices and the guidance documentation will be subject to final approval by the JAA and the EEC. It is anticipated that they will be promulgated in January 1993 for final implementation no later than January 1996. Some states are likely to pre-empt this date. During the final meeting of the Drafting Group, it was agreed that there was a need to examine certain problem areas in cardiology as part of an ongoing process to make licensing standards as safe, even and fair as possible. It was agreed that an initial attempt should involve the setting up of a workshop similar to the First and Second Workshops in the subject held in the United Kingdom'12-151. It was hoped that such a format would prove successful, as before, but there would be no obligation to hold a further workshop unless it was felt that such an approach had been
Appeals and their substance
The U.K. Civil Aviation Authority (CAA), in common with other European agencies and the Federal Aviation Administration (FAA) in the United States of America, has an appeals procedure which permits the consideration and certification of applicants technically falling outside the ICAO minimum standard. The Panel is chaired by the Chief Medical Officer, CAA and attended by a number of cardiologists, specialists from other branches of medicine (endocrinology; otolaryngology; oncology) with an interest in the aviation environment, the airlines, the unions and other observers. It was set up in 1977. By 1983, 61 cases had been reviewed, all cardiovascular apart from eight (sarcoidosis (2), diabetes (1), loss of consciousness (2), duodenal ulceration (1), hepatitis (1), haemophilia (1)). There was a brief pause in activity in anticipation of the first U.K. workshop but in the years 1984-1991 inclusive, 142 recommendations were made, four more being outstanding at the time of going to press. Five only did not involve the specialty of cardiology (malignancy (2), renal transplantation (1), adrenogenital syndrome (1), overactivity (1)). During this period, there were approximately 15 000 Class I and II (professional) and 40 000 Class III (private pilot) certificate holders. It is not a simple matter to represent the nuances of the decisions made by the Medical Advisory Panel although they are summarized in Table 2. Of note are those professional pilots certificated without restriction with possible coronary artery disease (2), both had suffered atypical chest pain but had a normal or near normal coronary angiogram; with left bundle branch block (3), one technically had left anterior hemiblock only, all had otherwise normal hearts; with Wolff-Parkinson-White pattern (1), an initial applicant who following electrophysiological study was felt to be at 'no excess risk' and with atrial fibrillation (1) — a 29-year-old with a single selfterminating episode with an otherwise normal heart. Recommendations took account of the work of the first and second U.K. workshops|l21151 and the constraints of the ISARPs'31. Even with a more explicit standard (Annex 1) it is inevitable that such licensing dilemmas will continue to arise and will need to be examined by a specialist advisory structure. Table 3 records the special issuances of licences by the FAA'271. Air carrier pilots, i.e. those flying passenger air transportation operations require Class I certificates while Class II certificates or better are required for air-taxi aircraft and other aircraft performing aerial work. Class III certification relates to private pilot flyers. It is not yet clear how ICAO paragraph 1.2.4.8. will be applied in this environment and it is likely that there will be some pan-European Medical Advisory Committee which will be empowered to adjudicate on appeals against licensing decisions. The present autonomy enjoyed by individual
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The European Civil Aviation Conference (ECAC)
successful in the pan-European environment. The United Kingdom, as Chairman of the Drafting Group, was charged with the responsibility of organizing what was to be the First European Workshop in Aviation Cardiology.
Cardiological aspects ofaviation safety 25
European nations in the application of the ICAO waiver clause, is thus likely to be lost to some extent and would be subsumed by such a committee. Conclusion Full harmonization of (medical) standards for aviation in Europe will be in place by 1996. After this date it will be possible to obtain a medical certificate in any one of the JAA signatory nations. Certificatory problems will, in part, be resolved with the help of guidance material in the European manual of Civil Aviation Medicine1281. Difficult decisions will still need specialist guidance and in view of the rate of progression in medicine and in other fields of activity, it is likely that in due time a further in depth review of cardiology in aviation will be needed.
[22] Tunstall-Pedoe H. Acceptable cardiovascular risk in aircrew. Eur Heart J 1988; 9 (Suppl G): 9-11. [23] General aviation accident review 1987; CAP542. Cheltenham, Civil Aviation Authority, 1988. [24] Learmount D. Is nothing safe? Flight Int 1992; 141:20-6. [25] Booze CF Jr. Sudden inflight incapacitation in general aviation. Aviat Space Environ Med 1989; 60: 332-5. [26] Auflret R, Charetteur MP. The European aeronautical environment. Eur Heart J 1992; 13 (Suppl H): 10-12. [27] Dark SJ. Federal Aviation Administration. 1991. Oklahoma City, Personal Communication. [28] Joy M. Class I cardiovascular standards with footnotes for Class II standards in European Manual of Civil Aviation Medicine. Joint Aviation Authority. Neuilly-sur-Seine. In press.
Annex 1 PART 4 CHAPTER 2 — CLASS 1 MEDICAL STANDARDS (PROPOSED*)
American College of Cardiology. Am J Cardiol 1966; 18:630-6. [9] Cardiovascularproblemsassociatedwithaviationsafety. Eighth Bethesda Conference of the American College of Cardiology. Am J Cardiol 1975; 36: 573-620. [10] EpsteinSE.Lirmtationsofelectrocardiographicexercisetesting. NEngJMed 1979; 301 264-5. [11] Cardiovascularfitnessof airline pilots. Report of the Working Party of the Cardiology Committee of the Royal College of Physicians of London. Br Heart J 1978; 40: 335-50. [12] Joy M, Bennett G, eds. The First U.K. Workshop in Aviation Cardiology. Eur Heart J 1984; 5 (Suppl A): 1-164. [13] Joy M. Introduction and summary of principle conclusions to the First U.K. Workshop in Aviation Cardiology. Eur Heart J 1984; 5 (Suppl A): 1-7. [14] Tunstall-Pedoe H. Risk ofa coronary heart attack in the normal population and how it might be modified inflyers.Eur Heart J 1984; 5 (Suppl A): 43-9. [ 15] Joy M, Bennett G, eds. The Second U.K. Workshop in Aviation Cardiology. Eur Heart J 1988; (Suppl G): 1-192. [16] Tunstall-Pedoe H. The concept of risk. Eur Heart J 1988; 9 (Suppl G): 13-15. [17] Chaplin J. In perspective — the safety of aircraft, pilots and their hearts. Eur Heart J 1988; 9 (Suppl G): 17-20. [18] Bennett G. Aviation accident risk and aircraft licensing. Eur Heart J 1984; 5 (Suppl A): 9-13. [19] Tyler A. How actuaries and underwriters look at risk. Eur Heart J 1988; 9 (Suppl G): 31-5. [20] The operation of aircraft. International standards and recommended practices. Annex 6 to the International Convention on Civil Aviation. Montreal; 1983: ICAO. [21] Learmont D. The arrogant decade. Flight Int 1990; 137: 4199: 48-50.
JAR-FCL 4-2.02 Cardiovascular system — blood pressure (a) The blood pressure shall be recorded with the technique given in para 3 of Appendix I to this Chapter. (1) When the blood pressure consistently exceeds 160mmHg systolic and/or 95mmHg diastolic with or without treatment the applicant shall be assessed as unfit. (2) Therapeutic agents used for the control of blood pressure shall be compatible with the safe exercise of the privileges of the applicable licence(s) (see para 4 of Appendix I to this Chapter). The initiation of drug therapy requires a period of temporary suspension of the medical certificate to establish the absence of significant side effects. (3) Applicants with symptomatic hyptension shall be assessed as unfit. JAR-FCL 4-2.03 Cardiovascular system — coronary artery disease (a) Suspected coronary artery disease shall be investigated. Asymptomatic, minor, coronary artery disease may be considered fit by the AMB if the applicant can fulfil the requirements of para 5 of Appendix I to this Chapter. (b) Applicants with symptomatic coronary artery disease shall be assessed as unfit.
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JAR-FCL 4-2.0J Cardiovascular system — examination (a) The holder ofa Class I medical certificate shall not possess any abnormality of the cardiovascular system, [1] Gibbs-Smith CH. Aviation: A historical survey from its origins congenital or acquired, which is likely to interfere with the to the end of World War II. London; 1970: HMSO. [2] Schurmier HL. Observations on the physical effects of flying. safe exercise of the privileges of the applicable licence(s). JAMA 1917; 69: 584-6. (b) A standard 12 lead resting electrocardiogram is [3] Personnel licensing. International Standards and Recommended required at the examination for first issue of a medical Practices. Annex 1 to the Convention on International Civil certificate, at renewal examinations annually to the 50th Aviation Medicine. Montreal, 1987: ICAO. birthday and six monthly thereafter. [4] Manual of Civil Aviation Medicine. Montreal; 1974: ICAO. [5] Manual of Civil Aviation Medicine, 2nd edn. Montreal; 1985: (c) Exercise electrocardiography is required only when ICAO. indicated on clinical grounds in accordance with para 1 [6] Joy M. A risk orientated approach to the problems of cardiovascular certification in aircrew: summary of principle con- Appendix I to this Chapter. (d) Estimation of serum/plasma lipids, including clusions of the Second U.K. Workshop in Aviation Cardiology. Eur Heart J 1988; 8 (Suppl G): 1-8. cholersterol, to facilitate risk assessment is required at the [7] First International Symposium on Cardiology and Aviation. examination for first issue of a medical certificate, at age Lamb LKE, ed. School of Aviation Medical Centre (ATC), 30 and 5-yearly thereafter (see para 2 Appendix I to this Texas, Brooks Air Force Base, 1959. [8] Standards offitnessin aircrew. First Bethesda Conference of the Chapter.
References
26 M. Joy
(c) Applicants shall be assessed as unfit following myocardial infarction. A fit assessment may be considered by the AMB subject to para 6 of Appendix I to this Chapter. (d) Applicants demonstrating satisfactory recovery 9 months followingcoronary by-pass surgery or angioplasty may be assessed asfitby the AM B in accordance with para 7 of Appendix I to this Chapter.
JA R-FCL 4-2.05 Cardiovascular system — miscellaneous (a) Applicants with peripheral vascular disease shall be assessed as unfit, before or after surgery, unless there is no significant functional impairment and the absence of coronary artery disease has been demonstrated. Applicants with aneurysm of the aorta, before or after surgery, shall be assessed as unfit. (b) Applicants with significant abnormality of any of the heart valves shall be assessed as unfit. (1) Cases of minor cardiac valvular abnormality may be assessed as fit by the AMB following cardiological evaluation in accordance with para 9 (a) of Appendix I to this Chapter. (2) Cases of cardiac valve replacement/repair shall be assessed as unfit. Favourable cases may be assessed as fit by the AMB following cardiological evaluation in accordance with para 9 (b) of Appendix I to this Chapter. (c) Systemic anticoagulant therapy is disqualifying. Treatment of limited duration may be considered fit by the AMB in accordance with para 10 of Appendix I to this Chapter. (d) Applicants with any abnormality of the pericardium, myocardium or endocardium shall be assessed as unfit until complete resolution has occurred or following cardiological evaluation in accordance with para 11 of Appendix I to this Chapter. (e) Applicants with congenital heart conditions, before or after corrective surgery, shall be assessed unfit. Applicants with minor abnormalities may be assessed fit by the AMB following cardiological investigation in accordance with para 12 of Appendix I to this Chapter.
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JA R-FCL 4-2.04 Cardiovascular system — rhythm/ conduction disturbance (a) Applicants with disturbance of atrial rhythm whether paroxysmal or established shall be assessed as unfit pending cardiological evaluation in accordance with para 8 of Appendix I to this Chapter. (b) Applicants with asymptomatic sinus bradycardia and tachycardia may be assessed as fit in the absence of significant underlying pathology. (c) Evidence ofsinotrial disease requires cardiological assessment in accordance with para 8 of Appendix I to this Chapter. (d) Applicants with asymptomatic isolated uniform ventricular ectopic complexes need not be assessed as unfit but frequent or complex forms require full cardiological evaluation in accordance with para 8 of Appendix I to this Chapter. (e) In the absence of other abnormality, applicants with incomplete bundle branch block or stable left axis deviation may be assessed as fit. Applicants with complete right or left bundle branch lock require cardiological evaluation on first presentation in accordance with para 8 of Appendix I to this Chapter. (f) Applicants with ventricular pre-excitation shall be assessed unfit unless cardiological evaluation confirms that the applicant fulfills the requirements of para 8 to Appendix I to this Chapter.
(g) Applicants with an endocardial pacemakers shall be assessed unfit unless cardiological evaluation confirms that the requirements of para 8 of Appendix I to this Chapter can be met.
Cardiological aspects of aviation safety — the new European perspective M.JOY
Civil A nation Authority, Medical Division, A viation House, Gatwick A irport South, W. Sussex RH6 0 YR KEY WORDS: Aviation, aircrew licensing, Europe, safety.
Medical standards in aviation Following the armistice in 1919, the League of Nations created the International Commission of Air Navigation which made recommendations to member states and included, inter alia, medical fitness requirements for the issuance of flying licenses. In the United Kingdom, the responsibility fell to the Air Ministry (MA2 division) and similarly in other countries, military authorities were the responsible agencies. The convention on International Civil Aviation was signed in Chicago on 7 December 1944 and included a number of articles calling for the adoption of international regulations to aid uniformity in air navigation. In 1947, the International Civil Aviation Organisation (ICAO) was founded and charged with implementing the provisions of the Chicago convention. It promulgated a series of regulations known as Standards and Recommended Practices (SARPs) which appeared as annexes to the convention, each annex dealing with a specific aspect of civil aviation. Correspondence: M. Joy, Civil Aviation Authority, Medical Division, Aviation House, Gatwick Airport South, W. Sussex RH6 OYR. 0195-668X/92/0H0O21 + 06 S08.00/0
Aviation medicine is primarily dealt with in Annex 1 (personnel licensing)131 but also referred to in Annex 2 (rules of the air) and Annex 6 (operation of aircraft). All nations are signatories to ICAO and bound thereby by international treaty to maintain (or enhance) the standards laid down. In the event of impossibility of compliance, notification to the Council of ICAO is compulsory under article 38. In 1970, the Personnel/Training/Medical (PEL/TRG/ MED) Divisional Meeting concluded that there was a need for suitable guidance material to assist the application of the SARPs, including those in Annex 1. Following the recommendation of the technical body of ICAO (the Air Navigation Commission), a medical study group was set up to prepare suitable material and in 1974, the ICAO Manual of Civil Aviation Medicine was published'41. In 1980, the Medical Director General of ICAO convened a cardiovascular study group meeting to review theexistingstandards and guidance material incardiology. The chapter on the cardiovascular system was re-written and a second edition of the manual was subsequently published in 1985'51
Cardiovascular standards in aviation The statements with regard to cardiovascular health in the ICAO annex are necessarily general statements (see Table 1 )'31 and although individual states may not require a lower standard than those laid down by ICAO, it is possible under Annex 1.2.4.8. for fitness requirements to be waived in special circumstances where the applicant's failure to meet any requirements . . . 'is such that exercise of the privileges of the licence applied for is not likely to jeopardize flight safety''351. In effect, many nations have used this rule to develop theijasic ICAO SARPs with particular application to cardiology in its role as the major cause of professional aircrew licence loss in the Western World'61. The first symposium to consider in detail the problems of cardiology in aviation took place in 1959171. In 1966, the American College of Cardiology recommended that resting electrocardiography should form part of the routine assessment of aircrew181 and the same College, later on in a more comprehensive review of the subject, recommended exercise electrocardiography should form part of the routine scrutiny of aircrew19'. This recommendation was not accepted by any licensing authority, and in any event, the recommendation has been displaced by ICAO requirements with regard to aircrew training for the eventuality I 1992 Tbe European Society of Cardiology
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Introduction When we arose in the morning of the 17 (December 1903) the puddles of water . . . were covered with ice. The wind had a velocity of 22-27 mph . . . . The course of the flight was extremely erratic . . . . This flight lasted only 12 s, but nevertheless was the first in the history of the world in which a machine carrying a man raised itself by its own power... [1l This shaky beginning at Kill Devil Hill, North Carolina saw the birth of powered flight although it was to be another 5 years before the first passenger was carried, by the same pilot over a distance of 2-5 miles in just under 4 min. Seventy years later, the Anglo-French Concorde was carrying 100 passengers across the North Atlantic Ocean. At twice the speed of sound it was exceeding the velocity of a rifle bullet and the capability of the majority of fighter aircraft belonging to the world's air forces. Aircraft development has been given substantial impetus by the conflicts of the 20th Century and early in the history of (military) aviation it was recognised that there was a need for standards of medical fitness for aircrew121. Pilots during the First World War were required to undergo 'strenuous physical examination' in which special attention was paid to vision and the organs of equilibrium. Those showing 'marked nervous tendency' were turned downpl
22 M. Joy
Table V"
The ICA O cardio vascular standards
of incapacitation on the flight deck'3', and, a better understanding of probability analysis'101. In the United Kingdom, the Royal College of Physicians set up a working party which considered the problem over a 3-year period, eventually publishing its recommendations in 19781'". The first U.K. workshop
Many of the statements made in these various reports were empirical and based on what cardiologists felt was appropriate, often without having any detailed knowledge or understanding of the inherent risk and safeguards in civil aviation. In order to improve on what was often an uneven and potentially unfair approach to the problems of cardiological certification, the First United Kingdom Workshop in Aviation Cardiology was convened in July 1982'121. The origins of this workshop to some extent stemmed from the Medical Advisory Panel to the U.K. Civil Aviation Authority, which had been set up in 1977. During the meetings of this Panel, it had become evident that there was a need to bring together the available data on natural history, incidence of complications, and the impact of intervention of a number of the more common conditions in order to define cardiovascular fitness to fly with greater precision'131. The workshop ran over 3 days, working sessions in which each included a moderator and between five and eight discussants. All participants were required to precirculate their material, these submissions forming the basis of the proceedings of the workshop, which was subsequently published as a supplement to the European
The second U.K. workshop
The approach of the First Workshop was developed in the Second'151. The format was the same and an additional section was added on risk seen from the point of view of an epidemiologist''61 a licensing agency1'7'81 and an actuary1'91. Chaplin'171 indicated that no transportation system was free from risk and the controlling legislation did not require it to be so. It had to be 'safe enough'. It was also indicated'17'181 that in multi-crew operations (where crew training for the possibility of incapacitation is mandatory) the target fatal accident rate was one event in 107 flying hours'6-181. Furthermore, medical cause accidents should not form more than 1 % of the total accident experience, implying that medical cause accidents to multi-crew aircraft should not exceed one event in 108— 109flyinghours. In the past 5 years, the fatal accident rate has remained at about one event in every 6 x 105 flying hours'21', while a cardiological cause accident rate is probably better than one event in 2-5 x 108flyinghours'6181. Similarly, in a single crew operation in which the fatal accident rate is likely to equal the serious incapacitation rate, and in which the observed accident rate is of the order of one event in 105flyinghours, by extrapolation the objective for medical cause accidents should not exceed one event in 107 flying hours. This coincides with the annual cardiovascular mortality rate in U.K. males aged 45 years or less'221. Observational data suggests that this target is being achieved. The 1 % rule and professional aircrew licensing
The targets outlined above have been developed into what has become known as the' 1 % rule1'221. This rule may be defined as the predicted annual medical (cardiological) event rate which, if exceeded, should excludea professional airman from flying a multi-crew aircraft. A 1% risk of
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6.3.2.5 The applicant shall not possess any abnormality of the heart, congenital or acquired, which is likely to interfere with the safe exercise of the applicant's licence and rating privileges. A history of proven myocardial infarction shall be disqualifying. Note. — Such commonly occurring conditions as respiratory arrhythmia, occasional extrasyswles which diasppear on exercise, increase of pulse rate from excitement or exercise, or a slow pulse not associated with auriculo-ventricular dissociation may be regarded as being within 'normal' limits. 6.3.2.5.1 Electrocardiography shall form part of the heart examination for the first issue of a licence and shall be included in reexaminations of applicants between the ages of 30 and 40 no less frequently than every two years, and thereafter no less frequently than annually. Note I. — The purpose of routine electrocardiography is case finding. It does not provide sufficient evidence to justify disqualification without further thorough cardiovascular investigation. Note 2. — Guidance on resting and exercise electrocardiography is published in the ICAO Manual of Civil Aviation Medicine (Doc 8984-AN 1895). 6.3.2.6 The systolic and diastolic blood pressure shall be within normal limits. Note I. — The use of drugs for control of high blood pressure is disqualifying, except for those drugs the use of which, according to accredited medical conclusion, is compatible with the safe exercise of the applicant's licence and rating privileges. Note 2. — Extensive guidance on the subject is published in the ICAO Manual of Civil Aviation Medicine (Doc 8984-AN1895) 6.3.2.7 There shall be no significant functional or structural abnormality of the circulatory tree.
Heart Journal^. Section headings included Hypertension and Biochemical Risk Factors, Coronary Artery Disease, Arrhythmias and Electrophysiology, and Valvular Heart Disease, Congenital Heart Disease and Cardiomyopathy. Emphasis was placed on epidemiology, and participants were chosen for their special expertise in the cardiological aspects of the subjects chosen for review. Initial briefing of the aviation operational environment was given at the American Airline simulator complex at Gatwick. Tunstall-Pedoe"41 made a significant contribution by suggesting that (cardiovascular) event rates could be expressed in the same units as aircraft accident rates, commonly events/million h. This emphasized the position of the airman as one component in an operational loop in which any one of the individual constituent parts could fail. Likewise in engineering terms, there are target event rates with the objective of maintaining the probability of catastophic failure at or below a predetermined minimum level. He also drew attention to the highly age- and sexdependent relationship of cardiovascular risk and the relative lack of efficacy of special screening tests on the overall population event rate.
Cardiological aspects ofaviation safety 23
Table 2
UK CAA medical advisory panel decisions 1984-1991 inclusive Licence I
2
II
IIR
III
8t 2
8t
IIIR
U
Total
7 2 6
6 6* 4
30 12 18 1 1 1 3 3 5
1 1 1
4
2 1
3
2 6
1 3 1 1
1 1 4 1
2 7 3 5 2
2 1
2
1 3
15
53
5 11 6 12 3
i
i
l
l
1
1 2 6 I 137
6 1 15
6 9
1
32
(f)oneand (*)two of these subjects underwent coronary angioplasty (i.e. fourin all). Licence types, I: air transpo rt of passengers and air traffic controllers (ATCO), II: airwork (crop-spraying, instruction); III: private. The suffix R denotes a restriction i.e. to multicrew operations (Oass I) or to carry a safety pilot (Class III). U: unfit any category.
event per annum corresponds with one event per 100 years or approximately one event per 106 h. It is the cardiovascular mortality rate of a male aged 60-65 in the U.K.'221 and is based on the assumption that 10% of the flight may be 'critical' (i.e. take-off, climb out, descent, approach, landing) and that in 1% of events occurring during this critical period, the mission may not be retrievable1'81. With a cardiovascular event rate of one in 106 hours, it should be possible to achieve a medical cause accident rate in multi-crew operations in line with the stated target — one accident in every 108 flying hours. Such a generous target should not be acceptable for single-crew commercial operations and any pilot approaching this predicted event rate should be required to have his licence endorsed to fly 'as or with co-pilot' under ICAO annex 1.2.4.Sfc)13'. The evolution of these targets requires the cardiologist to indicate only the likely event rates in an individual and not to make an empirical judgment with regard to the certificability or otherwise of a given airman. The ' 1 % rule' has proved both practical and workable over a number of years in the U.K. in its application to professional aircrew certification. It necessarily makes certain assumptions and it should be noted that the operational environment has changed somewhat. Orginally long haul, transoceanic flights all used aircraft carrying three crew, (two pilots and a flight engineer) whereas 'short haul' operations increasingly employed two pilots only. With increased automation and better standards of
reliability, two-crew aircraft now fly the world on long haul operations without always the need for a backup crew. Whether the ' 1 % rule' is as applicable to these operations needs debate as the pressure on the performance of a remaining crew member under the circumstances of incapacitation of his/her colleague is likely to be significant.
The medical standards for private pilots (JAA Class II) also bear consideration. In the U.K. and in other countries, the fatal accident rate in this group approximates 1 in every 40 000 h flown'23', this being 10-20 times worse than the prevailing scheduled airline accident rate'24'. As the majority of operations flown by private pilots are single crew, total incapacitation of the pilot in command will almost inevitably lead to an accident. If it is proposed that not more than 1 in 25-50 of all fatal accidents to private aircraft should be due to medical cause (cf above: 1 in 100 for Class I operations), then the cut-off point for Class II certificate holders may also be drawn when the predicted cardiovascular event rate exceeds 1 in 1 million flying hours, or, approximately 1 % per annum. Such a target has the advantage that it is concordant with that for Class I holders with licences endorsed to fly 'as or with co-pilot' and consistent with the observed medical incapacitation fatal accident rate in the largest data set
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Myocardial infarction Coronary artery disease Coronary artery bypass grafting Muscle bridge Athletes heart Myocarditis Aortic valve disease Aortic valve replacement AV conduction anomaly Hypertrophic/Dilated cardiomyopathy Left bundle branch block Wolfe-Parkinson-White syndrome VPB/VTach Sinoatrial DIS/SVT Atrial fibrillation Peripheral vascular disease AV malformation Heart transplant Hypertension Pacemaker Congenital (fallot) Total
IR
24 M. Joy
Table 3 1991
FAA special issuances of medical certificates as of 1 July
Priority list description Coronary artery bypass surgery Myocardial infarction Coronary artery/heart disease Aortic valve replacement Mitral valve replacement Implanted pacemaker Carotid artery disease Angioplasty
First class
Second class
106 108 73 15 2 1 23 1
179 114 81 23 7 5 37 5
available1251. It would be difficult to define an acceptable standard based on such principles to permit restricted certification of Class II certificate holders with lesser standards of fitness.
As part of the ongoing European Harmonization Process'261, it was proposed that there should be mutual recognition of licences for aviation personnel and this implied a common medical standard for the aircrew of member nations. The European Civil Aviation Conference (ECAC) was tasked jointly by the EEC and ICAO to evolve the Joint Airworthiness Authorities (now the Joint Aviation Authorities) which is to have responsibility for the regulation of all aspects of aviation in Europe. A number of subgroups, including a Flight Crew Licensing (FCL) Medical Subgroup, were detailed to write a comprehensive medical standard based on an interpretation ofthelCAOSARPs. Various Drafting Groups were set up by the FCL Medical Subgroup, one of which examines certificatory standards in cardiology. This group was chaired initially by the United Kingdom (later by Denmark) and attended by representatives of Denmark, Finland, Ireland, France the Netherlands and Portugal. The recommended standards and their associated appendices were accepted by the FCL Medical Subgroup in the Summer of 1992 (see Annex I). Guidance material interpreting the standards was written by the United Kingdom and accepted at the same time. These standards, their associated appendices and the guidance documentation will be subject to final approval by the JAA and the EEC. It is anticipated that they will be promulgated in January 1993 for final implementation no later than January 1996. Some states are likely to pre-empt this date. During the final meeting of the Drafting Group, it was agreed that there was a need to examine certain problem areas in cardiology as part of an ongoing process to make licensing standards as safe, even and fair as possible. It was agreed that an initial attempt should involve the setting up of a workshop similar to the First and Second Workshops in the subject held in the United Kingdom'12-151. It was hoped that such a format would prove successful, as before, but there would be no obligation to hold a further workshop unless it was felt that such an approach had been
Appeals and their substance
The U.K. Civil Aviation Authority (CAA), in common with other European agencies and the Federal Aviation Administration (FAA) in the United States of America, has an appeals procedure which permits the consideration and certification of applicants technically falling outside the ICAO minimum standard. The Panel is chaired by the Chief Medical Officer, CAA and attended by a number of cardiologists, specialists from other branches of medicine (endocrinology; otolaryngology; oncology) with an interest in the aviation environment, the airlines, the unions and other observers. It was set up in 1977. By 1983, 61 cases had been reviewed, all cardiovascular apart from eight (sarcoidosis (2), diabetes (1), loss of consciousness (2), duodenal ulceration (1), hepatitis (1), haemophilia (1)). There was a brief pause in activity in anticipation of the first U.K. workshop but in the years 1984-1991 inclusive, 142 recommendations were made, four more being outstanding at the time of going to press. Five only did not involve the specialty of cardiology (malignancy (2), renal transplantation (1), adrenogenital syndrome (1), overactivity (1)). During this period, there were approximately 15 000 Class I and II (professional) and 40 000 Class III (private pilot) certificate holders. It is not a simple matter to represent the nuances of the decisions made by the Medical Advisory Panel although they are summarized in Table 2. Of note are those professional pilots certificated without restriction with possible coronary artery disease (2), both had suffered atypical chest pain but had a normal or near normal coronary angiogram; with left bundle branch block (3), one technically had left anterior hemiblock only, all had otherwise normal hearts; with Wolff-Parkinson-White pattern (1), an initial applicant who following electrophysiological study was felt to be at 'no excess risk' and with atrial fibrillation (1) — a 29-year-old with a single selfterminating episode with an otherwise normal heart. Recommendations took account of the work of the first and second U.K. workshops|l21151 and the constraints of the ISARPs'31. Even with a more explicit standard (Annex 1) it is inevitable that such licensing dilemmas will continue to arise and will need to be examined by a specialist advisory structure. Table 3 records the special issuances of licences by the FAA'271. Air carrier pilots, i.e. those flying passenger air transportation operations require Class I certificates while Class II certificates or better are required for air-taxi aircraft and other aircraft performing aerial work. Class III certification relates to private pilot flyers. It is not yet clear how ICAO paragraph 1.2.4.8. will be applied in this environment and it is likely that there will be some pan-European Medical Advisory Committee which will be empowered to adjudicate on appeals against licensing decisions. The present autonomy enjoyed by individual
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The European Civil Aviation Conference (ECAC)
successful in the pan-European environment. The United Kingdom, as Chairman of the Drafting Group, was charged with the responsibility of organizing what was to be the First European Workshop in Aviation Cardiology.
Cardiological aspects ofaviation safety 25
European nations in the application of the ICAO waiver clause, is thus likely to be lost to some extent and would be subsumed by such a committee. Conclusion Full harmonization of (medical) standards for aviation in Europe will be in place by 1996. After this date it will be possible to obtain a medical certificate in any one of the JAA signatory nations. Certificatory problems will, in part, be resolved with the help of guidance material in the European manual of Civil Aviation Medicine1281. Difficult decisions will still need specialist guidance and in view of the rate of progression in medicine and in other fields of activity, it is likely that in due time a further in depth review of cardiology in aviation will be needed.
[22] Tunstall-Pedoe H. Acceptable cardiovascular risk in aircrew. Eur Heart J 1988; 9 (Suppl G): 9-11. [23] General aviation accident review 1987; CAP542. Cheltenham, Civil Aviation Authority, 1988. [24] Learmount D. Is nothing safe? Flight Int 1992; 141:20-6. [25] Booze CF Jr. Sudden inflight incapacitation in general aviation. Aviat Space Environ Med 1989; 60: 332-5. [26] Auflret R, Charetteur MP. The European aeronautical environment. Eur Heart J 1992; 13 (Suppl H): 10-12. [27] Dark SJ. Federal Aviation Administration. 1991. Oklahoma City, Personal Communication. [28] Joy M. Class I cardiovascular standards with footnotes for Class II standards in European Manual of Civil Aviation Medicine. Joint Aviation Authority. Neuilly-sur-Seine. In press.
Annex 1 PART 4 CHAPTER 2 — CLASS 1 MEDICAL STANDARDS (PROPOSED*)
American College of Cardiology. Am J Cardiol 1966; 18:630-6. [9] Cardiovascularproblemsassociatedwithaviationsafety. Eighth Bethesda Conference of the American College of Cardiology. Am J Cardiol 1975; 36: 573-620. [10] EpsteinSE.Lirmtationsofelectrocardiographicexercisetesting. NEngJMed 1979; 301 264-5. [11] Cardiovascularfitnessof airline pilots. Report of the Working Party of the Cardiology Committee of the Royal College of Physicians of London. Br Heart J 1978; 40: 335-50. [12] Joy M, Bennett G, eds. The First U.K. Workshop in Aviation Cardiology. Eur Heart J 1984; 5 (Suppl A): 1-164. [13] Joy M. Introduction and summary of principle conclusions to the First U.K. Workshop in Aviation Cardiology. Eur Heart J 1984; 5 (Suppl A): 1-7. [14] Tunstall-Pedoe H. Risk ofa coronary heart attack in the normal population and how it might be modified inflyers.Eur Heart J 1984; 5 (Suppl A): 43-9. [ 15] Joy M, Bennett G, eds. The Second U.K. Workshop in Aviation Cardiology. Eur Heart J 1988; (Suppl G): 1-192. [16] Tunstall-Pedoe H. The concept of risk. Eur Heart J 1988; 9 (Suppl G): 13-15. [17] Chaplin J. In perspective — the safety of aircraft, pilots and their hearts. Eur Heart J 1988; 9 (Suppl G): 17-20. [18] Bennett G. Aviation accident risk and aircraft licensing. Eur Heart J 1984; 5 (Suppl A): 9-13. [19] Tyler A. How actuaries and underwriters look at risk. Eur Heart J 1988; 9 (Suppl G): 31-5. [20] The operation of aircraft. International standards and recommended practices. Annex 6 to the International Convention on Civil Aviation. Montreal; 1983: ICAO. [21] Learmont D. The arrogant decade. Flight Int 1990; 137: 4199: 48-50.
JAR-FCL 4-2.02 Cardiovascular system — blood pressure (a) The blood pressure shall be recorded with the technique given in para 3 of Appendix I to this Chapter. (1) When the blood pressure consistently exceeds 160mmHg systolic and/or 95mmHg diastolic with or without treatment the applicant shall be assessed as unfit. (2) Therapeutic agents used for the control of blood pressure shall be compatible with the safe exercise of the privileges of the applicable licence(s) (see para 4 of Appendix I to this Chapter). The initiation of drug therapy requires a period of temporary suspension of the medical certificate to establish the absence of significant side effects. (3) Applicants with symptomatic hyptension shall be assessed as unfit. JAR-FCL 4-2.03 Cardiovascular system — coronary artery disease (a) Suspected coronary artery disease shall be investigated. Asymptomatic, minor, coronary artery disease may be considered fit by the AMB if the applicant can fulfil the requirements of para 5 of Appendix I to this Chapter. (b) Applicants with symptomatic coronary artery disease shall be assessed as unfit.
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JAR-FCL 4-2.0J Cardiovascular system — examination (a) The holder ofa Class I medical certificate shall not possess any abnormality of the cardiovascular system, [1] Gibbs-Smith CH. Aviation: A historical survey from its origins congenital or acquired, which is likely to interfere with the to the end of World War II. London; 1970: HMSO. [2] Schurmier HL. Observations on the physical effects of flying. safe exercise of the privileges of the applicable licence(s). JAMA 1917; 69: 584-6. (b) A standard 12 lead resting electrocardiogram is [3] Personnel licensing. International Standards and Recommended required at the examination for first issue of a medical Practices. Annex 1 to the Convention on International Civil certificate, at renewal examinations annually to the 50th Aviation Medicine. Montreal, 1987: ICAO. birthday and six monthly thereafter. [4] Manual of Civil Aviation Medicine. Montreal; 1974: ICAO. [5] Manual of Civil Aviation Medicine, 2nd edn. Montreal; 1985: (c) Exercise electrocardiography is required only when ICAO. indicated on clinical grounds in accordance with para 1 [6] Joy M. A risk orientated approach to the problems of cardiovascular certification in aircrew: summary of principle con- Appendix I to this Chapter. (d) Estimation of serum/plasma lipids, including clusions of the Second U.K. Workshop in Aviation Cardiology. Eur Heart J 1988; 8 (Suppl G): 1-8. cholersterol, to facilitate risk assessment is required at the [7] First International Symposium on Cardiology and Aviation. examination for first issue of a medical certificate, at age Lamb LKE, ed. School of Aviation Medical Centre (ATC), 30 and 5-yearly thereafter (see para 2 Appendix I to this Texas, Brooks Air Force Base, 1959. [8] Standards offitnessin aircrew. First Bethesda Conference of the Chapter.
References
26 M. Joy
(c) Applicants shall be assessed as unfit following myocardial infarction. A fit assessment may be considered by the AMB subject to para 6 of Appendix I to this Chapter. (d) Applicants demonstrating satisfactory recovery 9 months followingcoronary by-pass surgery or angioplasty may be assessed asfitby the AM B in accordance with para 7 of Appendix I to this Chapter.
JA R-FCL 4-2.05 Cardiovascular system — miscellaneous (a) Applicants with peripheral vascular disease shall be assessed as unfit, before or after surgery, unless there is no significant functional impairment and the absence of coronary artery disease has been demonstrated. Applicants with aneurysm of the aorta, before or after surgery, shall be assessed as unfit. (b) Applicants with significant abnormality of any of the heart valves shall be assessed as unfit. (1) Cases of minor cardiac valvular abnormality may be assessed as fit by the AMB following cardiological evaluation in accordance with para 9 (a) of Appendix I to this Chapter. (2) Cases of cardiac valve replacement/repair shall be assessed as unfit. Favourable cases may be assessed as fit by the AMB following cardiological evaluation in accordance with para 9 (b) of Appendix I to this Chapter. (c) Systemic anticoagulant therapy is disqualifying. Treatment of limited duration may be considered fit by the AMB in accordance with para 10 of Appendix I to this Chapter. (d) Applicants with any abnormality of the pericardium, myocardium or endocardium shall be assessed as unfit until complete resolution has occurred or following cardiological evaluation in accordance with para 11 of Appendix I to this Chapter. (e) Applicants with congenital heart conditions, before or after corrective surgery, shall be assessed unfit. Applicants with minor abnormalities may be assessed fit by the AMB following cardiological investigation in accordance with para 12 of Appendix I to this Chapter.
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JA R-FCL 4-2.04 Cardiovascular system — rhythm/ conduction disturbance (a) Applicants with disturbance of atrial rhythm whether paroxysmal or established shall be assessed as unfit pending cardiological evaluation in accordance with para 8 of Appendix I to this Chapter. (b) Applicants with asymptomatic sinus bradycardia and tachycardia may be assessed as fit in the absence of significant underlying pathology. (c) Evidence ofsinotrial disease requires cardiological assessment in accordance with para 8 of Appendix I to this Chapter. (d) Applicants with asymptomatic isolated uniform ventricular ectopic complexes need not be assessed as unfit but frequent or complex forms require full cardiological evaluation in accordance with para 8 of Appendix I to this Chapter. (e) In the absence of other abnormality, applicants with incomplete bundle branch block or stable left axis deviation may be assessed as fit. Applicants with complete right or left bundle branch lock require cardiological evaluation on first presentation in accordance with para 8 of Appendix I to this Chapter. (f) Applicants with ventricular pre-excitation shall be assessed unfit unless cardiological evaluation confirms that the applicant fulfills the requirements of para 8 to Appendix I to this Chapter.
(g) Applicants with an endocardial pacemakers shall be assessed unfit unless cardiological evaluation confirms that the requirements of para 8 of Appendix I to this Chapter can be met.
