Medical Attention

Avatar for Sarah B. HoodBy Sarah B. Hood | February 24, 2012

Estimated reading time 9 minutes, 40 seconds.

A recent report from the Transportation Safety Board (TSB) following the crash of a Grumman TBM-3E being used as a water bomber in New Brunswick has raised concerns about Canada medical assessment system for pilots. Are civil aviation medical examiners (CAMEs) receiving all the information they need to ensure that Canadian pilots are fit to fly? 
The TBM-3E, owned by Forest Protection Limited, took off from Miramichi Airport for a practice flight on a clear April afternoon in 2010. Although it was manufactured in 1954, the aircraft was judged after the crash to have been properly maintained and in good shape. The 62-year-old pilot, employed by the company for a decade, had logged about 260 hours in this particular type of aircraft and a total of about 13,530 hours of flight time over his career.
Nonetheless, minutes after takeoff and with no emergency transmissions, the TBM-3E ploughed into the ground, killing the pilot and destroying the aircraft. The TSB study revealed that, although the pilot had a normal ECG record dating from the previous month and a Transport Canada (TC) Category 1 medical examination dated only 16 days before the fatal crash, the cause of the incident was a sudden mid-air heart attack.
Mid-air coronary attacks are rare, but they would seem to be the most frequent cause of death for pilots in flight, apart from combat situations, and they are not limited to small aircraft. In 2007, a Continental Airlines flight from Texas to Mexico was diverted after the pilot died during the flight; in 2011, co-pilots landed a U.S.-bound Continental flight from Brussels after the captain succumbed to heart failure. In October of 2010, the pilot of a Qatar Airways A330 Airbus died of a heart attack while flying from the Philippines to Qatar, forcing an emergency landing in Kuala Lumpur. 
Even young military pilots are at risk; in March of 2011, a 28-year-old Sri Lankan air force pilot lost control of his Kfir fighter jet, causing a mid-air crash after he suffered a heart attack while flying in formation. In 2009, a resourceful passenger managed to land a King Air, relying only on instructions from air traffic controllers, after the pilot succumbed to heart failure shortly after takeoff from Florida en route to Mississippi. (The passenger did hold a pilot licence, but had only logged about 150 hours in a Cessna 172.)
International aviation authorities do not publish standard statistics on these types of incidents; however, various special studies provide a snapshot of the world situation. A 2004 study for the U.S. Federal Aviation Administration Office of Aerospace Medicine reported four pilot deaths from 1993 to 1998, all due to cardiac illness; these planes landed successfully with no other fatalities.
A 2007 report for Australia Transportation Safety Board found that between 1975 and 2006, Australian flight crews reported eight cases of in-flight heart attacks, representing 8.16% of all situations involving the medical incapacitation of crew members. Of these, five were fatal. 
On Oct. 18, 2011, Occupational Health and Safety Canada magazine published an article titled TSB Report Puts Pilot Health, Fitness Under Microscope, in response to the TSB report on the crash of the Forest Protection Limited TBM-3E. The article observed that, despite Canada much smaller population, When compared to the United States, Canada has a much higher number of aircraft incidents caused by cardiovascular issues. From January 1976 to October 2008 there were 38 incidents in Canada, 28 resulting in fatalities. In the U.S., there were only 13 such incidents from 1982 to 2011.
Jon Stuart, senior human performance investigator with the TSB, was one of the investigators on the Forest Protection Limited incident. The Board was concerned about how Transport Canada is screening for coronary risk in the aviation community, and this accident demonstrated that the guidelines that are used don’t always pinpoint the risks, he said. The Board is also concerned that medical practitioners mainly family doctors don’t always understand the need to report medical conditions.
In the case of the Miramichi pilot, a succession of indicators did not predict conclusively that his coronary health would put him and others at risk. Normally, the health of all pilots must be assessed by a CAME before they can be licensed to perform their duties. Maryse Durette, Transport Canada senior media relations advisor, explained: When someone is identified as having risk factors for cardiovascular disease, additional testing is requested such as blood tests, a cardiologist consult and/or an exercise stress test. Depending on the results, she added, additional tests or consults may be requested [and] the certificate may be suspended or restricted. Typical restrictions would include the requirement to fly with another pilot or to submit to medical examination more often. As long as individuals continue to meet the department medical requirements, they can continue to hold a licence.
However, CAMEs need the input of family doctors in order to make the best possible assessment of a pilot fitness to fly, and there is sometimes a gap in this communication link. Over the years, Transport Canada has publicized the requirement for pilots to tell their family doctors that they are pilots; why the family doctors are not always aware of this, I don’t know, said Stuart.
The Canadian Medical Association (CMA) publishes a document called Determining Medical Fitness to Operate Motor Vehicles, generally referred to as the Driver Guide, which is currently in its seventh edition, dating from 2006. Its 10-page Section 24, dedicated specifically to aviation, opens with the statement that, Physicians are required by law to report to regional aviation medical officers of Transport Canada any pilots, air traffic controllers or flight engineers with a medical condition that could affect flight safety. The guide is updated from time to time; in fact, said CMA media relations manager Lucie Boileau, The CMA looks to experts in the areas covered within the Driver Guide and, as such, has recently contacted Transport Canada to determine whether the current chapter on aviation requires a revision.
Although the TBM-3E pilot was judged fit to hold a licence based on the assessment of his CAME, the TSB accident report states that he had a history of hypertension dating from 1998 and he had been taking medication to treat this condition. This information was not reported to TC by the pilot family physician; however, it was reported by the pilot during his 2008 TC aviation medical examination. Between 1998 and 2008, each of the pilot TC medical reports recorded that he had not seen a physician during the time between TC medical exams, despite having made numerous visits to his family physician.
Furthermore, the report notes, On the morning of the occurrence flight, the pilot had a grey complexion and was sweating, which can indicate heart problems. Autopsy results concluded the pilot suffered from ischemic heart disease.
A wide range of things can cause a pilot to become incapacitated, and the civil aviation medical system is set up to screen for the majority of these conditions, said Stuart. What the Board is highlighting is that we need modern benchmarks and really rigorous screening to cut down the risk here.
[This case] raises a red flag; it one clear instance where cardiovascular risk went undetected, he continued. We don’t have a clear idea of how serious this risk is; that why the Board has seen fit not to make a recommendation at this moment, but to flag it as a concern.
Transport Canada has been actively reviewing the cardiovascular guidelines issued to CAMEs since 2010, said Durette. Although there is no legal obligation to respond to a Board concern, Transport Canada will respond in this case, with an anticipated response out in early 2012.
Furthermore, she said, In the coming months, Transport Canada will write to the Canadian Medical Association and provincial medical regulatory bodies to address how physicians and patients might better inform the department of significant health issues in pilots and other medical certificate holders.
Sarah B. Hood is a Toronto author and journalist who has contributed to dozens of newsstand and trade publications. She has been shortlisted for both the National Magazine Awards and the Kenneth R. Wilson Awards for business writing.

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