Jogging to a Different Medical Standard

Revised regulations acknowledge some advances, ignore others

May 1, 1996

Changes to Federal Aviation Regulations Part 67 medical standards have been contemplated for two decades — so long that two American Medical Association studies commissioned by the FAA, the most recent of which was completed in 1986, no longer can be viewed as current medical opinion.

Between October 1994, when a notice of proposed rulemaking announced airman medical certification changes, and the close of the ensuing comment period in February 1995, the FAA received 5,200 written responses — an unusually large number of pilot comments to an NPRM. Three public hearings were held, and numerous articles appeared in aviation publications (see "The Case Against Tougher Medical Standards," February 1995 Pilot).

Almost none of the comments supported stricter standards, and it took the FAA 13 months to publish the final rule. Now the clock runs swiftly, as the rules become effective on September 16 — and the changes will affect most pilots who hold medical certificates.

Probably the most sweeping change is the extension of the Class III medical certificate term to three years for all pilots under age 40. This will affect about 45 percent of pilots who hold Class III certificates. However, in typical FAA style, this extension is valid only for certificates issued after September 16 — the certificate you now hold is not valid past its current expiration date.

There is no reasonable explanation for the FAA's excluding pilots from an immediate extension. The new regulation states that the three-year term will apply to pilots who have not reached age 40 by the date of their medical examination. For some pilots the exact date on which they receive their certificate will determine the length of time for which the certificate is valid.

Pilots over age 40 have not been granted any relief, although there are no valid studies to show that these pilots would have more medically related accidents with less frequent examinations. The FAA withdrew its effort to make pilots over age 70 submit to annual medical certification; the agency could not justify the cost effectiveness of that initiative.

Vision

Several changes will facilitate the certification of pilots with color vision or visual acuity deficiencies. Such pilots were routinely granted medical certificates after demonstrating their ability to perform safely, but it took time and effort by the applicant, the aviation medical examiner (AME), and the FAA. The new standards are reasonable and reflect how certification of such pilots through the waiver process has been handled for many years.

The distant vision standards for all pilots will be simpler. An applicant need only demonstrate eyesight of 20/20 or better in each eye separately, with or without correction, to qualify for Class I or II; and 20/40 or better in each eye, with or without correction, to qualify for Class III. The "with or without correction" added to each standard means that some pilots who previously would require a statement of demonstrated ability (SODA) will be saved an administrative hassle. An AME will be able to issue their certificate on the spot without a waiver.

Near vision standards have been slightly revised. Pilots in all classes must have vision of 20/40 or better at 16 inches (reading distance) in each eye separately, with or without correction. This is not a change for Class I. However, it is stricter than the previous rule requiring Class II pilots to prove visual accommodation sufficient to read official aeronautical maps at 16 inches, and the lack of regulatory Class III near vision standards. A few private and commercial pilots will be affected by the 20/40 standard.

A new regulation for Class I and II applicants age 50 and older requires good intermediate vision. AMEs will test vision at instrument panel distance — 32 inches. An acuity of 20/40 or better in each eye separately, with or without correction, will be required. It is difficult to argue against requiring a hired pilot to read aircraft instruments, although the FAA admits that no documented accidents have occurred because of such a deficiency.

The FAA has taken a reasonable approach with color vision. A pilot need only "perceive those colors necessary" for safe piloting. Unfortunately the FAA has not defined which colors they consider "necessary" for flight. Waivers are now granted to pilots who can distinguish control-tower light gun signals of red, green, and white. Will the FAA impose new practical tests, like the ability to distinguish colors on a VFR aeronautical sectional chart? The answer to this and several other questions will depend upon the written advice in the promised revision of the Guide for Aviation Medical Examiners.

Hearing and equilibrium

The hearing standard has been made more sensible. A pilot need only prove the ability to understand conversational speech at six feet, using both ears to do so. AOPA would like to have seen the standard extended to pilots who can meet this spoken voice test with a hearing aid. Such pilots routinely obtain certification with a waiver. Assuring that a pilot can hear conversation is what is important, but even totally deaf applicants can be issued medical certificates — although they are limited to flight not requiring aural communication.

The standards have been specifically expanded to disqualify pilots with diseases or conditions that can cause vertigo or disturbance of equilibrium.

Hypertension and cardiac disorders

After threatening to impose stricter standards, the FAA eliminated regulatory blood pressure limits. It has omitted the age-dependent Class I standards and eliminated the long- established Class II and III 170/100 Guide for Aviation Medical Examiners standard. Hypertension is no longer specifically mentioned in the regulations. However, if the pilot has hypertension and requires medication, as determined by his personal physician, the FAA will probably require a cardiovascular workup as it has in the past. This is reasonable, as the current 170/100 ceiling for Class II and III is much higher than most physicians feel should go untreated.

Several new cardiovascular procedures will now specifically disqualify applicants. While cardiac valve replacements, permanent pacemakers, and cardiac transplants were the basis for disqualification on general medical grounds, the FAA wanted to remove the opportunity for appeal to the National Transportation Safety Board. Qualification of such individuals now will be exclusively at the discretion of the federal air surgeon, and not appealable to an administrative law judge or the NTSB.

The FAA has yet to match regulations to the increasing success of these cardiac procedures. In the past the NTSB gave medical certificates to certain cardiac transplant and cardiac valve replacement patients over the objections of the FAA. These pilots have not proven to impose a safety hazard, but they will now require special issuances on September 16 or when they apply for renewal of their certificates thereafter. Pilots who already have special issuance for cardiovascular reasons — or for any other medical problem — will not be affected. Renewal of each special issuance by proffering the results of diagnostic examinations and tests remains a requirement as in the past. As of 1994 there were 77 pilots with special issuance for pacemakers and 95 with tissue or mechanical cardiac valve replacements.

The new regulations also close a small loophole. Now, under FAR 61.53, pilots with a recent cardiac valve, pacemaker, or cardiac transplant might resume flying within the term of their current medical certificate if cleared by their own physicians and if they thought that medical standards were met, because these conditions are not now specifically disqualifying. That will no longer be the case. A pilot with any of these medical histories will be immediately disqualified and can fly as pilot in command only after obtaining a special issuance. The federal air surgeon usually requires at least six months to lapse before considering such discretionary issuance.

Class I applicants over age 40 will now have to submit an electrocardiogram performed within 60 days of their examination, instead of the current 90 days. This should affect only ATPs who have their cardiogram done at a time and place different from that of their aviation medical examination.

Legally speaking

The FAA has taken an unusual step in making portions of the regulations age dependent. It is surprising that the agency was willing to risk the appearance of age discrimination.

Several new legal considerations have been added to the regulations concerning pilots whose certificates are issued at the discretion of the federal air surgeon. For example, special issuances will now be called authorizations. If the FAA withdraws a certificate, the pilot must surrender the certificate. It may not be retained. A certificate, authorization, or statement of demonstrated ability based on a false or incorrect statement — even if inadvertent — will be the basis for suspension, revocation, or denial.

The FAA had threatened to append the phrase "include, but are not limited to" to each medical condition listed as disqualifying. Most commentators objected to giving the FAA such unchecked authority, and the FAA decided not to expand the scope of the regulations in this way.

The FAA says that there are circumstances in which the NTSB and the courts "confirmed a rule does not achieve the FAA's intent." The FAA believes that it has the right to rewrite such regulations and, after the fact, bar a pilot who has obtained a favorable appellate ruling. The FAA deems that reviewing authorities have only disagreed with its interpretation of rules, and that its policies are not defective. We suspect that pilot petitioners and their lawyers feel otherwise.

When can diabetics fly?

In 1991, the American Diabetes Association (ADA) petitioned to allow special issuance for insulin-requiring diabetics. Three years later, a select panel of endocrinologists presented guidelines by which the federal air surgeon could grant special issuance to persons who use insulin; this resulted in an official proposal. In December 1994 the FAA published a request for comments on the proposed guidelines.

Despite overwhelmingly favorable response, the FAA still has not adopted a policy to certify these individuals. Pointed arguments and pressure by AOPA, ADA, other organizations, and individuals have not succeeded in moving the FAA to act. Meanwhile, the FAA program for diabetic air traffic controllers has been an unqualified success.

Drugs not worse than alcohol

The new regulations do not incorporate the FAA proposal for five years' abstinence from drugs before considering recertification. Two years will be the regulatory abstinence period for all "substances" as it has been for alcohol. In practice, airline pilot alcoholics are often allowed to return to duty in six months with appropriate monitoring, but it is unlikely that the FAA will be as lenient with drug addiction or abuse. The new regulations define substances as alcohol; sedatives; hypnotics (sleeping pills); anxiolytics (Librium, Valium, Xanax); opioids (narcotics); central nervous systems stimulants such as cocaine, amphetamines (speed), and similarly acting sympathomimetics; hallucinogens (LSD); phencyclidine (PCP) or similarly acting arycyclohexylamines; cannabis (marijuana); inhalants (glue); and other psychoactive drugs and chemicals. Specifically excluded from the definition are tobacco and caffeine, although they are also addictive.

An applicant who has failed a drug test under the auspices of the Department of Transportation will now be disqualified under the new regs, and be barred from medical certification for at least two years.

Mental disqualification

The FAA has added bipolar disorder, commonly known as manic depressive disorder, to the list of conditions that will medically disqualify pilots. Because accepted psychiatric terminology no longer classifies this mental disorder as a psychosis, the FAA does not want to consider such applicants for certification under the standards simply because they are not psychotic. However, neither the old nor new rules preclude applicants with any disqualifying disorder from requesting a special issuance.

Somewhat more restrictive, but no safer

The new regulations are, on balance, favorable to most pilots. Unfortunately, the FAA has not proven that the more restrictive changes will improve flight safety in even a small way. The FAA needs to consider that pilots are living longer and healthier lives. Few aviation accidents are attributable to pilot health, and even fewer would be predicted by more extensive certification procedures. Diseases are becoming more treatable and less incapacitating. Now is not the time for stricter medical standards. FAA efforts to improve aviation safety should be directed toward the most frequent causes of accidents, such as weather and pilot error.

The tortured history of medical revisions

In 1979, AOPA petitioned the FAA to extend the duration of Class III medical certificates to three years for pilots of all ages. It took the FAA more than three years to respond to this initiative. On October 29, 1982, the agency proposed Class III medical examinations every five years for young pilots and then with increasing frequency to the existing two-year interval for older pilots. In 1985 the FAA withdrew this proposal "because of issues raised by the medical community." Though outweighed by pilots and most aviation- knowledgeable physicians, the opinion of a small but vocal group of aviation medical examiners allowed the FAA to duck this issue. The FAA also cited a then-pending AMA report.

The FAA began a review of airman medical standards by requesting public comment in 1982. It spent $697,882 on a 400-page report that the AMA published on March 26, 1986. This tome purported to review pertinent advances in medicine since the last substantial revision of medical standards in 1959. We could identify few pilots among the 71 contributors to the study, which makes costly recommendations for stricter standards.

For 10 years the FAA considered the AMA report and comments it engendered. It used the report as a shield to deflect all public initiatives to consider changes in aviation medical regulation. This included petitions concerning myocardial infarction by the Civil Pilots for Regulatory Reform and several AOPA initiatives. In February 1990, after consultation with its medical advisory panel, AOPA sought changes in the color vision, visual acuity, and cardiovascular standards. Seventy-nine out of 80 written comments favored these revisions. However, the FAA gave weight to the Air Line Pilots Association International (ALPA) opposition and considered the AOPA recommendations "premature."

The FAA at that point had been cogitating for at least eight years on such issues. Again in June 1990, AOPA petitioned to grant limited privileges to pilots pending FAA action on medical certification renewal. Many pilots were experiencing unfounded delays in processing their deserved certification. Also included in the petition was a proposed change in the two-year required abstinence from alcohol to a period "reasonable to ensure abstinence." This was the de facto standard the FAA was applying to airline pilots with Class I certificates. AOPA also petitioned for medical certification of diabetics using oral hypoglycemic medication. Again the only opposing comment was from ALPA. Citing the active rulemaking project and ALPA, the FAA delayed any decision.

Once more, in September 1993, AOPA petitioned to revise the duration of Class III medical certificates to four years on a trial basis. The FAA did not reply until now, but the agency says that it considered this petition.

The FAA does not practice medicine

The FAA now recognizes that it is not empowered to practice preventive medicine, and for this reason the agency has withdrawn proposals for Class II electrocardiograms, Class I blood cholesterol testing, and yearly certification for Class III pilots over age 70. It says that it will issue rules only where there is clear evidence that safety is enhanced and at a reasonable cost. However, the FAA will continue to monitor accident and health data and threatens the imposition of such requirements in the future. "In the coming months [the FAA will] explore alternate non-regulatory means to reduce medically related accidents," the FAA states in the final rule. These alternative means "will assist pilots and aviation medical examiners in identifying and reducing potential medical risks." Members of the AOPA Medical Advisory Panel are anxious to learn if the FAA has knowledge, unknown to us and not already applied to the pilots we examine, that will reduce aviation medical risks.

Pilots' new medical regulation checklist

The revised Federal Aviation Regulations regarding airman medical certification will affect you if you:

  1. Will not be age 40 before September 16, 1996, plan to have a medical examination before your fortieth birthday, and require only a Class III certificate. Tip: If you will be younger than 40 on your next birthday, it would be beneficial to renew your medical certificate after September 16, if possible, in order to get a three-year certificate.
  2. Have problems with distant or near vision. (See the special case of intermediate vision for Class I and II over age 50.)
  3. Have a hearing problem.
  4. Have deficient color vision.
  5. Had a positive test for drugs, or a substance abuse problem in the past two years.
  6. Had a cardiac transplant, pacemaker, or valve replacement.
  7. Have a statement of demonstrated ability (waiver) or special issuance based on erroneous information or incorrect statements, even if inadvertent.
  8. Have a disease or condition that can cause vertigo or loss of equilibrium.
  9. Have manic depressive (bipolar) disorder.
  10. Have your electrocardiogram for Class I performed at a different time than your aviation medical examination.

Ian Blair Fries, M.D., chairs the AOPA Medical Advisory Panel and assists AOPA in developing positions on aviation medical issues. He is a senior AME, CFII, ATP, and the newest member of the of the AOPA Air Safety Foundation board of visitors. He often writes and lectures on aviation medical issues, and is the author of the textbook The Pilot's Medical Advisor.