CASA’s policy about aeromedical decision
making (ADM) in respect of mature pilots
Aviation Medicine Branch
Industry Permissions Division
CASA
Table of contents
The context ................................................................................................................................ 3
What is aviation medicine? ....................................................................................................3
Legal Framework for regulatory aviation medicine ...............................................................3
International ..................................................................................................................... 3
Domestic ........................................................................................................................... 4
System of Regulatory Aviation Medicine in Australia ............................................................5
Regulatory Medical Decision Making ............................................................................... 5
Developing policy.............................................................................................................. 8
The Issue raised by this paper ................................................................................................... 9
The Legislation .......................................................................................................................9
The CASA CAA policy development meeting .........................................................................9
Outcomes of the meeting ............................................................................................... 10
Periodicity of testing ....................................................................................................... 11
Implementation .................................................................................................................. 12
Appendix.................................................................................................................................. 13
List of requirements (consolidated) .................................................................................... 13
ADM in Mature pilots – Position paper
Civil Aviation Safety Authority
Page 2 of 13
The context
What is aviation medicine?
Aviation medicine is the branch of medicine concerned with the human capacity to
safely and effectively perform complex tasks in the potentially hostile aviation working
environment. Although clinical aviation medicine largely involves the physical and
mental health of aircrew and passengers exposed to a wide range of environmental
stresses, aviation medicine is also an applied science which embraces experimental
physiology, bio-dynamics, psychology and human factors, the neurosciences and
scientific study of the special senses.
Regulatory aviation medicine, outside of the military, is the application of aviation
medical knowledge and expertise to regulatory aspects of the civil aviation sector.
Throughout the world, most of the practice of civil aviation regulatory medicine involves
the assessment of professional and non-professional pilots and air traffic controllers
against defined medical standards. Some refer to this in relation to flight crew as ‘fit to
fly’ or ‘fitness to fly’ determinations.
In Australia, aviation medicine is not a recognised discrete medical speciality but is often
considered a branch of the preventative or occupational medicine speciality. The main
specialist aviation medicine qualifications recognised within Australasia are the postgraduate Diplomas of Aviation Medicine awarded by Otago University or the Royal
College of Physicians (UK). In other countries, including the United States, Canada, Great
Britain and India, aviation medicine is recognised as a discrete medical speciality and is
often referred to as Aerospace medicine.
Medical practitioners who have completed a CASA approved course can register with
CASA as Designated Aviation Medical Examiners (DAMEs), and are then qualified to
medically examine pilots and air traffic controllers to certify their fitness for work.
Legal Framework for regulatory aviation medicine
International
The 1944 Convention on International Civil Aviation ("the Chicago Convention") provides
the basis for the unification and standardisation of safety-related civil aviation law.
Australia is a signatory to the Chicago Convention. Among other things, the Chicago
Convention established the International Civil Aviation Organisation (ICAO), which has as
one of its functions the adoption of international standards and practices. Once
adopted, these are designated as annexes to the Chicago Convention.
These standards and recommended practices and procedures relate to a variety of
matters including air navigation, registration of aircraft and the certification of
personnel, such as flight crew. Where a Contracting State does not adhere to these
Standards it must notify ICAO of the differences to enable the Council to notify all
Member States.
ADM in Mature pilots – Position paper
Civil Aviation Safety Authority
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The first Annex to the Chicago Convention (“Annex 1”), titled “Personnel Licensing”, states
(Note 2 to 1.2.4) that -–
“To satisfy the licensing requirements of medical fitness for the issue of various types of
licences, the applicant must meet certain appropriate medical requirements which are
specified as three classes of Medical Assessment”.
The ICAO medical provisions for licensing, including the medical standards, are
prescribed in Chapter 6 of Annex 1. Section 6.1.1 of Annex 1 and describe three classes
of medical assessment: class 1, class 2, and class 3. These three classes of medical
assessment apply to aviation personnel licences as follows:
Class 1: Applies to applicants for, and holders of commercial pilot licences, airline
transport pilot licences, flight engineer licences, or flight navigator licences.
Class 2: Applies to applicants for, and holders of private pilot licences, glider pilot
licences, or free balloon pilot licences.
Class 3: Applies to applicants for, and holders of air traffic controller licences.
The standards contained within Chapter 6 of Annex 1 have generally been implemented
in Australian law.
Domestic
The Australian civil aviation medical certification system is governed by the Civil Aviation
Act 1988 (“the Act”), the Civil Aviation Regulations 1988(CAR), and the Civil Aviation
Safety Regulations 1998(CASR).
The Act, Part 5 of the CAR, and Part 67 of the CASR (Part 67) contain the main legislative
requirements in relation to pilot licences and the role of medical certificates in enabling
the exercise of the privileges of a pilot licence.
Part 5 of the CAR deals with pilot licences and ratings. It requires a current medical
certificate for an individual to exercise the privileges of his/her pilot licence. In relation
to a medical certificate, “current” means that the holder of the certificate has satisfied
the medical requirements and the medical certificate is valid and has not expired or
been revoked or suspended.
Part 67 of the CASR contains the medical standards. Consistent with the ICAO
requirements these medical standards and the medical certificates that are issued, are
divided into three classes which relate to the exercise of the privileges of the different
types of licences as follows:

Class 1 - airline transport pilot licence, commercial pilot licence, or flight
engineer licence;

Class 2 - private pilot licence or any person who wishes to fly solo; and

Class 3 - required to be held by persons wishing to exercise the privileges of an
air traffic controller licence.
ADM in Mature pilots – Position paper
Civil Aviation Safety Authority
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Medical certificates are subject to differing maximum validity periods prescribed in
Subpart 67.205(3) of the CASR. The maximum validity period varies with the class of
medical certificate, type of aviation activities, and with the age of the holder of the
medical certificate.
There are presently over 37,000 pilot and air traffic controller licences on issue from
CASA. These licenses are divided between approximately 17,000 private pilot licences,
5700 commercial pilot licences, 7500 airline transport pilot licences, 600 air traffic
controller licences, and the rest a combination of student pilot and other licenses.
Approximately 23,000 Australian civil aviation medical certificates were issued during
the last twelve months and approximately 4500 of these were first-time certifications.
The medical practitioners involved directly in the Australian medical certification system
include over 700 DAMEs spread throughout Australia and overseas and the medical staff
of the CASA Office of Aviation Medical. The CASA medical certification system also
utilises the opinions of a wide variety of clinical medical specialists such as psychiatrists,
neurologists, and cardiologists.
System of Regulatory Aviation Medicine in Australia
Regulatory Medical Decision Making
The CASA develops and administers medical standards (CASR Pt 67) applicable to licence
holders in air transport and general aviation operations as well as for air traffic control
operations. As indicated above, in developing regulations, CASA uses the Standards and
Recommended Practices for medical fitness for licence holders as stated in Chapter 6 of
Annex 1 to the Chicago Convention. CASA also prepares associated guidance material
and issues advice in relation to the above matters.
In assessing the more complex or difficult cases, the medical officers of CASA apply a
philosophy of evidence-based, risk management to regulatory aviation medical
considerations. All decisions are a result of a collegial process.
Collegial
The collegial aspect of the process involves using more than one medical officer in the
consideration of complex cases. Those medical officers seek to achieve consensus with
respect to the final conclusion. This component of the philosophy is intended to ensure
consistent outcomes, provide a degree of internal peer review and focus a high level of
aviation medical expertise onto the case.
Evidence based
The evidence based aspect of the process is directed to ensuring that wherever possible
and appropriate the relevant medical and scientific research literature is searched,
reviewed and applied to the considerations of the case.
In assessing the evidence in support of any decision making, CASA uses the hierarchy of
evidence provided by the NHMRC (which largely mirrors the hierarchies of many other
august bodies internationally). A diagrammatic representation of this hierarchy is shown
below:
ADM in Mature pilots – Position paper
Civil Aviation Safety Authority
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By the very nature of the studies, any systematic reviews take time, and therefore will
often deal with studies that are a few years old This is recognised in the formation of
these hierarchies, as the value of the rigorous review outweighs the recency of the
information.
Additional medical clinical specialists, or others, may also be consulted to add clinical
and other experience and expertise to the pool of information under consideration. In
some medical conditions the published material has limited relevance to aviation
considerations, and it may be necessary to take recourse to material presented at
conferences.
Medical evidence is rarely perfect, or does not always exactly relate to the case under
consideration. Recognising the imperfection of medical evidence, CASA takes a view that
medical evidence should not be ignored because of its imperfection, but that the best
available medical evidence should be applied to a case in a reasonable manner. This may
sometimes involve generalising or extrapolating findings from the medical literature.
Risk Management
In an ideal world, there would be no risk associated with air travel such that flying would
be perfectly safe. Unfortunately, this is not the case. Air travel involves a complex
interplay between machines, people and the environment and each of these is subject
to either failure or unpredictability. It is not possible for aviation to be perfectly safe and
without risk, so most countries aim for some reasonable degree of safety.
Medical factors represent only one of a number of factors that can contribute to the risk
associated with air travel. Medical risk is usually managed so that a balance is achieved
where medical factors are neither the weak-link in aviation safety nor so restrictive that
virtually no-one is able to fly. Every aviation medical certification system that allows
people to fly aircraft involves the acceptance of some amount of medical risk.
If striking this medical balance is unsuccessful, in either direction, then the community
will be exposed to increased cost either through aircraft accidents with preventable
medical causes or through increased costs of compliance, increased rejection of pilots
on medical grounds and increased injury and death of pilots due to regimens of medical
testing.
ADM in Mature pilots – Position paper
Civil Aviation Safety Authority
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In making a medical certification decision, CASA Medical Officers consider the overall
risk that the applicant’s medical condition presents to aviation safety and the utility and
reliability of risk mitigation efforts. This includes a consideration of the individual’s age,
experience, type of flying, currency, extent of flying, the medical condition, the
treatment, possible side effects of treatment and a range of other similar and
interrelated issues.
The process is somewhat simplistically separated into six steps for ease of
understanding, though in practice the steps all merge into each other. This flow chart
helps to highlight the multiplicity of factors which apply in the making of these decisions.
It also helps to clarify the role of the clinical consultant, as being that of providing one of
the many components in this decision. Looking at in terms of the legislation, the clinical
specialist helps to identify whether the condition is safety relevant and then contributes
to the store of information about prognostic probabilities. This information is vital in the
next step of the process, but making the certification decision requires a different set of
information and expertise and a different skill set.
The flowchart on the next page shows the method that we use in making aeromedical
decisions.
ADM in Mature pilots – Position paper
Civil Aviation Safety Authority
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Regulatory Aeromedical Decision Making
Diagnosis
or sign/
symptom
complex
Population bias
Referral bias
Incidence and
prevalence
data
Determine
adequacy of
functional capacity
1
Determine
likelihood of
medical
incapacitation
2
Characteristics
of symptom/
sign
Aeromedical
stressors
Determine
likelihood of
unacceptable
outcome in-flight
3
4
Flight factors
Acceptable
level of risk
Risk acceptable?
Yes
No
Determine Risk
after likelihood
modification
5
Legend
Process
Risk acceptable after
likelihood
No
modification?
Yes
Decision
Manage
Consequences
6
Stored Data
End of process
Risk acceptable after
consequence
modification
Eligible to fly
Yes
No
Ineligible to fly
Developing policy
The development of policy in complex conditions is based on evidence-based risk
management. The Civil Aviation Safety Authority (CASA) generally makes policy changes in
connection with medical matters on the basis of relevant medical evidence. CASA convenes
meetings at least once every year to discuss an area which is of importance to aviation and
on which policies are in need of revision. The day long meetings are attended by expert
consultants, CASA doctors, often representatives of the Civil Aviation Authorities of New
Zealand and sometimes other jurisdictions, members of the unions, and industry bodies. The
purpose of meetings of this kind is to enable all issues to be canvassed and discussed in an
open and transparent manner, so that CASA’s policy makers have the benefit of the expert
information shared at these events, while at the same time enabling interested members of
the wider Australian aviation community to raise questions and come better to understand
the issues. The products of this exercise are intended to inform appropriate and
ADM in Mature pilots – Position paper
Civil Aviation Safety Authority
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implementable policy, and can shape CASA's policies in medical certification of pilots and air
traffic personnel.
The Issue raised by this paper
The topic for this meeting was the management of the aeromedical risks particular to
maturer pilots. This risk assessment is difficult because the onset of different clinical
conditions is extremely variable, and so chronological age is not a dependable indicator of
performance in all the different domains.
Mirroring the risk assessment approach common to all other clinical conditions, the
approach was centred on requiring applicants to demonstrate adequate performance of
critical systems (eg, cardiovascular, cognition, etc) where the statistical risks become
significant.
The Legislation
CASR Part 67 does not have a standard that is related to age. What is required is (emphasis
added):
67.180
Medical certificates — issue and refusal
(1) Subject to this regulation, on receiving an application under regulation 67.175,
CASA must issue a medical certificate to the applicant only if:
(a) the applicant meets the requirements of subregulation (2); or
(b) if subregulation (3) applies to the applicant — CASA is satisfied that issuing
the medical certificate to the applicant will not adversely affect the safety of
air navigation.
(2) For paragraph (1) (a), the requirements are:
(a) the applicant has undergone any relevant examinations that, in the opinion
of CASA, are necessary in the particular case; and
The CASA CAA policy development meeting
The meeting was held at in Melbourne in November 2011. The meeting was attended by all
CASA doctors, a DAME who attended as a member of AOPA, a DAME who attended as a
member of ASAM, a member of GAPAN, representatives from Virgin Australia and Qantas,
Regulatory doctors from CASA and CAA New Zealand, and the following specialists:

An occupational physician with experience of and expertise in managing age related
medical exams in other sectors

A Geriatrician

A neurologist specialising in geriatrics
ADM in Mature pilots – Position paper
Civil Aviation Safety Authority
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
A neurophysiologist

A cardiologist

A Designated Eye Examiner
All attendees had been provided with a copy of the results of a review of the scientific
literature around the subject, and many had done their own further subject reviews. The
meeting was conducted in an open and collaborative manner with all parties able to make
comments or pose questions to the specialists.
Outcomes of the meeting
The meeting formed the following views:

That chronological age was not a dependable indicator of performance as the onset
of the many problems of age was variable and not well predicted in an individual
case.

However, there was supporting evidence to link the onset of the following
conditions to age:

o
Cognitive decrement
o
Atrial fibrillation
o
Coronary artery disease
o
Glaucoma and visual field defects
o
Hearing defects
It was agreed that the statistical risk of these conditions increased after the late 50s
and increased steeply thereafter.
There was considerable discussion about the methods by which cognitive decrement should
be assessed. The options discussed were

Cogscreen or other psychometric testing

Review by a neuropsychologist

Mini Mental state exam

The Montreal Cognitive Assessment (MOCA)

Flight tests
CASA’s doctors have long supported the use of the flight test as being a good test of
cognitive function, and it is in use by CASA and CAA of NZ as a means of returning young
people with risk of cognitive defects following illness or injury. The specialist geriatricians
and the neurologist with expertise in cognitive testing pointed out that this testing by itself
was inadequate, because subtle changes missed in the flight tests could be picked up by
cognitive testing. They recommended that the assessment should consist of a test
ADM in Mature pilots – Position paper
Civil Aviation Safety Authority
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administered by the DAME, a flight test, and an overall assessment of the individual (during
the entire process of the medical examination), by the DAME.
There was discussion about the specific test to be used. Many good tests are available, and
were discussed. CASA was interested in having a valid and dependable test that was
accessible and available, effective, and cost as little as possible. The consensus of the
consultants was that the MOCA was a well validated test, did not take long (about 10
minutes), and had a high sensitivity and specificity. It also had the advantage of being
available freely at no cost.
The accepted process for assessment of cognition was decided to be a combination of:

MOCA

Flight test

DAME judgment
The process for assessment of visual field defects was decided to be a combination of:

Confrontation test at each medical examination

Periodic automated perimetry

A general eye examination
The process for assessment of Atrial fibrillation and coronary artery disease was decided to
be a combination of:

Resting ECG

Cardiac risk index scoring

Appropriate follow up in cases of abnormality
Hearing already has a standard in Part 67, and the assessment methodologies are already
clear, so this subject was not discussed in any great detail.
While it was clearly understood by all parties that CASA would form a policy view based on
the outcomes of the meeting, there were opinions expressed by the various experts to
suggest that a periodicity of 5 years between 60 and 70 years of age was the safe maximum,
with closer scrutiny after 70 years of age.
Periodicity of testing
Following the meeting, CASA formulated a table listing the details of the ages at which
different assessments are needed.
There is already an existing table that has been formulated based on risk, and the additional
assessments recommended by the panel at the meeting have been incorporated.
In devising this periodicity of assessment, it is noted that a feature of increasing ages is that
functional reserve is diminished, and therefore de-compensation can occur quickly. This
ADM in Mature pilots – Position paper
Civil Aviation Safety Authority
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necessitates increased scrutiny, as the individual can decline rapidly following the
assessment
The dates of consolidated table have been rationalised so as to “clump” most assessments in
specific years.
The schedule of tests is placed at Appendix to this document.
Implementation
The planned assessment schedule is offered for consultation. After any changes are made
following consultation, implementation is intended to be complete by the end of the first
quarter of 2013.
ADM in Mature pilots – Position paper
Civil Aviation Safety Authority
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Appendix
List of requirements
(consolidated)
Special Reports and Tests
Age (Yrs)
Ser., Lips & BI.GI
Audio
Eye
ECG
CVD Risk Score
INITIAL ISSUE
All
1, 3
1, 3
1, 3
1, 3
1, 3
All
2
No additional tests required unless clinically indicated
RENEWALS
25
1, 3
1, 3
1, 3
1, 3
30
1, 3
1, 3
1, 3
1, 3
32
1, 3
34
1, 3
35
1, 3
1, 3
1, 3
36
1, 3
38
1, 3
40
1, 3
1, 3
An ECG is
1, 3
45
1, 3
1, 3
required yearly
1, 3
50
1, 3
1, 3
from age 40
1, 3
55
1, 3
1, 3
for Class 1
1, 3
60
To be done
1, 3
1, 3
and every 2
Calculate each
62
every year over
1, 3
years for Class
year over 65
64
60 years
1, 3
3
for Class 1 & 3
65
1, 3
From age 66
66
2 as well
1, 2, 3
every 2 yrs
2 as well
68
1, 3
for Class 2
70
2 as well
1, 3
1, 2, 3
2 as well
72
1, 3
74
1, 3
75
2 as well
1, 3
1, 2, 3
2 as well
76
1, 3
78
1, 3
80+
Additional requirements advised individually
2 as well
No additional tests required unless clinically indicated
1= Class 1 Medical certificate
3= Class 3 Medical certificate
2= Class 2 Medical certificate
*Functional Checks
ADM in Mature pilots – Position paper
Civil Aviation Safety Authority
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MOCA + Flight Test
1, 2, 3*
1, 2, 3*
1, 2, 3*
Annually