Alcohol Abuse Control Programs for Corporate Aviation
Recent highly publicized events have highlighted alcohol problems in professional pilots. Alcohol abuse and dependence affects approximately 5-8% of all pilots, similar to the proportions in other professional occupations such as law, medicine and ministry. Most is undiscovered or unreported. Many people are unaware or deny that they are not able to fully control their consumption behavior.
Alcoholism is widely recognized as a progressive, fatal disease process beyond the control of an individual, not a weakness in character. Alcoholism has a specific cause, predictable course and responds to treatment. Untreated, it causes premature death, reduced productivity and may compromise aviation safety. With proper treatment, most alcoholics will have full and sustained remission. The result is improved health, social relationships, job performance and enhanced aviation safety.
The consequences to the individual pilot of alcohol abuse are potentially severe, including loss of both medical and pilot certificates, employment termination, legal troubles and life-threatening medical conditions. The consequences to the employer are equally threatening including public embarrassment, loss of revenue, compromised flight safety and possibly aircraft mishaps.
Without a mechanism for pilots to seek assistance for alcohol abuse, which allows them to retain their FAA certificates and employment, this condition will remain underground in all but the most obvious, and potentially disastrous, circumstances. Such a program exists in the airline industry. The FAA Office of Aerospace Medicine is seeking to enlist the involvement of the business aviation community in establishing a similar program to this highly successful program within their industry.
A cooperative, mutually supportive program between airline pilots, their management and the FAA, termed HIMS (Human Intervention Motivation Study), allows afflicted pilots to seek treatment and rehabilitation, leading to early FAA medical certification. Although drug/alcohol testing programs identify some abusers, most are identified by self-reporting, peers or in training departments. The program conservatively returns $9 for each $1 spent by management.
Over 3,600 airline pilots have successfully returned under HIMS to safe flying and health. Business aviation operations may use a similar program to enhance safety, improve pilot health and increase productivity.
Full Article (FAA-Sanctioned Pilot Alcohol Abuse Programs in Business Aviation)- Introduction
Recent highly publicized events have highlighted alcohol problems in professional pilots. The reports of pilots being arrested in the airport, or removed from the aircraft in handcuffs, following detection of alcohol on their breath by security screeners tarnishes the professional image of all pilots. The flying public justifiably demands the highest standards of safety and responsible behavior from aircrew.
Flight departments that ignore the issue of inappropriate substance use by aircrew may eventually be faced with embarrassing public relations situations. Companies that do not have a clearly defined, non-punitive mechanism for pilots to seek evaluation and treatment for potential substance abuse problems are unknowingly being adversely affected by the undiscovered problem. Alcohol and drugs compromise safety in pilot operations and maintenance procedures. The effects also include increased personnel costs, reduced productivity, less favorable working environments, and a higher liability profile.
In most cases, alcoholism in the corporate sector of the aviation industry is undiscovered, unrecognized and unreported. Education about the condition is the key to saving dollars, reputations, families, careers and lives. The FAA recognizes the value of education, intervention, treatment and return to flying duties for pilots afflicted by this common, progressive, fatal, but treatable, disease.
Substance Abuse and Dependence ? Definitions
The FAA defines a Substance as ?alcohol; other sedatives and hypnotics; anxiolytics; opioids; central nervous system stimulants such as cocaine, amphetamines, and similarly acting sympathomimetics; hallucinogens; phencyclidines or similarly acing arycyclohexyamines; cannabis; inhalants; and other psychoactive drugs and chemicals?. 14 CFR 67.107, 207 and 307
In laymen?s terms, alcohol means beer, wine, hard liquor, moonshine and other forms of alcohol. Sedatives, hypnotics and anxiolytics include compounds similar to Valium and barbiturates. Opioids are narcotics taken by prescription, such as Percocet and Oxycontin, and illegal street drugs, such as heroin. Cocaine includes crack cocaine. Amphetamines, also called ?speed? or ?uppers? are often used illegally by athletes attempting to lose weight, improve muscle definition or enhance performance. Phencyclidine is PCP or ?Angel Dust?. Cannabis is marijuana. Inhalants include substances such as glue and aerosol sprays as well as street drugs. In general, the variety of recreational compounds available on many college campuses covers most of the spectrum of Substances defined by the FAA.
The FAA defines Substance Dependence as ? a condition in which a person is dependent on a substance, other than tobacco or ordinary xanthine-containing beverages (e.g., caffeine) beverages as evidenced by ?
(A) Increased Tolerance;
(B) Manifestation of withdrawal symptoms;
(C) Impaired control of use; or
(D) Continued use despite damage to physical health or impairment of social, personal, or occupational functioning.? 14 CFR 67.107, 207 and 307
The above definition is rather broad. Many circumstances that people may not associate with substance dependence would meet the FAA definition. Examples include:
Walking and driving with a blood alcohol content of 0.20 mg/dl (Increased tolerance);
DTs, fast heart rates and irritability (Manifestations of withdrawal symptoms);
Drinking more than 5 drinks at a time (binging) or having an ?eye opener? (Impaired control)
Drinking despite liver test abnormalities, domestic abuse complaints associated with alcohol, divorce or use of sick leave due to hangovers or blackouts.
The FAA defines Substance Abuse as any event ?within the preceding two years [in which]
(1) Use of a substance in a situation in which the use has been physically hazardous, if there has been at any other time and instance of a substance also in a situation in which that use was physically hazardous;
(2) A verified positive drug test result conducted under an anti-drug rule or internal program or the U.S. Department of Transportation or any other Administration within the Department of Transportation;
(3) Misuse of a substance that the Federal Air Surgeon, based on case history and appropriate, qualified medical judgment relating to the substance involved, finds ?
(i) Makes the person unable to safely perform the duties or exercise the privileges of the airman certificate applied for or held; or
(ii) May reasonably be expected, for the maximum duration of the airman medical certificate applied for or held, to make the person unable to perform those duties or exercise those privileges.? 14 CFR 67.107, 207 and 307
Again, this is a broader definition than use by most medical professionals. The FAA considers any motor vehicle action related to alcohol as use in a physically hazardous manner. Even if charges were dropped or reduced after being stopped for a DUI/DWAI, the FAA considers these events alcohol related. By signing the Application for Airman?s Medical Certificate, FAA Form 8500-8, the airman gives consent for the FAA to search the National Driver?s Registry for all alcohol related traffic violations. Failing to reveal these on an FAA medical application may result in significant consequences.
Another example of use in a physically hazardous manner is alcohol use that results in a medical visit, such as going to the Emergency Room after tripping when drinking or having an abnormal heart rhythm due to alcohol. Finally, the last section of the FAR quoted above gives the Federal Air Surgeon and his designated medical consultants considerable leeway in determining an airman has abused a substance. Although the criteria used by the FAA are broad, they are reasonable given the overwhelming priority of public safety. Early identification of substance abuse problems has the benefit of potentially preventing some of the undesirable consequences of the condition.
The key to the diagnosis of any substance abuse is the ?Three C?s.?
1) Loss of ?Control?
2) ?Compulsive? use
3) Continued use despite adverse ?Consequences?
The spectrum of alcohol use is broad, both in psychological and physiological context and in a social context. On one end of the spectrum is the non-drinker. Approximately 15+% of the adult US population does not consume alcohol. Either they never started drinking or choose not to drink any longer for a variety of reasons. This percentage does not include alcoholics in remission.
The next step on the continuum of alcohol use is ?social? drinking. This is considered normal behavior and is characterized by an individual who can stop drinking at will. This group makes up 50-60% of the adult US population. Although, this behavior does not meet the criteria for abuse or dependence, people with genetic predisposition for addiction may be in the early stages leading to future abuse /dependence.
Alcohol abuse, as noted above, is characterized by use in a hazardous manner or having adverse social, personal, legal or occupational consequences. This is a disorder in which a person might be able to stop drinking to prevent future adverse consequences. It may also be a middle stage of the spectrum of alcohol use.
The late stage of alcohol use is dependence, characterized by an inability to stop, compulsive use and continued use despite adverse consequences.
The last stage of alcohol dependence leads to grave medical conditions and death. Alcoholism is a progressive, fatal disease if left untreated.
This paper focuses on alcoholism as the primary substance of abuse and dependence. However, the risks of any substance abuse and the benefits to the individual, family and employer of an effective treatment program are the same for all addictive substances.
A Medical Disease
Old stereotypes of alcoholism / chemical dependency mistakenly lead to the impression that these conditions are caused by mental weakness, lack of self-control, ignorance, stupidity or immorality. Modern medical practice supports the finding that chemical dependency is a disease.
Alcoholism is a Progressive, Relapsing, Chronic, Fatal Disease. It is Treatable.
Think of alcoholism as very similar to cancer, diabetes, heart disease and HIV. The FAA does.
Each of these conditions has very well defined diagnostic criteria. They have multi-factorial causes. There are specific signs, symptoms, laboratory tests and physical findings. All have a predictable course. Without adequate treatment, all are fatal diseases. Fortunately, all are treatable and have a usual, though not uniform, response to treatment. For pilots, the good news is that the FAA will certify pilots with these conditions if they are adequately treated and regularly monitored.
A useful exercise is a comparison of alcoholism to cancer. Alcoholism is beyond the control of the individual, as is cancer. There is a genetic predisposition to each disease, but not a certainty of acquiring the disease based on family history. Certain behaviors will lower the risk of each disease. Avoiding sun exposure, eating a high fiber diet, not smoking and other behaviors will lower the risk of cancer. Not drinking alcohol will lower the risk of alcohol dependence. The tendency to acquire both diseases still remains despite avoiding high-risk behavior. Engaging in sun tanning does not consistently lead to skin cancer. Similarly, many people can drink alcohol and not become abusers or dependent. Both sun tanning and drink are socially acceptable and appropriate behaviors, often done together.
The signs and symptoms of cancer are frequently missed by observers, denied by the afflicted individual and allowed to progress to a much more dangerous state before recognition and treatment. The signs and symptoms of alcoholism are addressed in a similar fashion. Often it takes a nearly catastrophic event for the individual, family, employer or physician to recognize the underlying progressive disease. This phenomenon is termed ?Denial? and is nearly universal in alcoholism and other addictive behaviors.
Once identified, both cancer and alcoholism are subject to careful diagnostic assessment to determine the extent of the disease and to evaluate any co-existing conditions.
A treatment plan is developed for each individual afflicted with these chronic, progressive, fatal diseases. The goal of the treatment plan is to address the immediate complications in the short term. The long-term goal is to keep the disease in remission. The treatment plans require regular, continuous and careful monitoring to prevent a relapse or detect an early relapse before the consequences are too severe.
The treatment options for cancer include surgery, radiation and chemotherapy. Long term suppressive medications may be given to lower the risk of recurrence once the disease is in remission. Regular monitoring of the cancer detects potential recurrences and allows early intervention.
The treatment for substance abuse is continuous, total ABSTINENCE. Working a 12 Step program daily helps keep the disease in remission. Regular monitoring of disease detects potential recurrences and allows early intervention. Recovery requires careful daily maintenance. Full and sustained recovery is possible, and in the aviation industry, probable.
Substance Abuse ? Incidence
Substance abuse is present in nearly all organizations of a dozen or more people. Alcohol abuse and dependence affects approximately 5-8% of all pilots, similar to the proportions in other professional occupations such as law, medicine and ministry. Maintenance personnel, flight attendants and management also are afflicted at the same rates.
The disease does not discriminate among professions, socioeconomic classes, gender, age, education levels or other factors. What differs is the ability to conceal the disease and delay adverse outcomes. Nationwide, approximately 13% of those diagnosed with alcoholism are employed in professional/technical careers. About 6% of alcoholics are unemployed, while ?street people? only represent about 1-3% of alcoholics. Some very productive and successful members of society are afflicted. Often they are extremely adept at denying or concealing their condition.
Alcoholism and substance abuse in the workplace, particularly in the aviation industry, are often undiscovered, unrecognized and unreported. The keys to minimizing the consequences are recognizing the possibility of the disease, committing to instituting a non-punitive program of assistance and educating the workforce and management about the program.
Substance Abuse ? Who It Impacts and Consequences
Alcoholism affects the physical health of the individual. As stated above, it is a progressive, fatal disease. Early manifestations include obesity (?beer belly?), high blood pressure, accidents and heart irregularities. As the condition progresses without treatment, liver disease (cirrhosis), bleeding ulcers and skin changes (swollen nose and red, dilated blood vessels known as ?spiders? on face and chest). Late stages of the disease are characterized by blackouts, seizures, withdrawal symptoms (DT?s) and death.
Alcoholism affects the mental health of the individual. One of the desired effects of alcohol consumption is the loss of behavioral inhibitions. This occurs at blood alcohol levels below legally intoxicated limits. Impairment of judgment occurs simultaneously. Nervousness, impatience and irritation develop. Insomnia and depression that follow often are ?self-medicated? with more alcohol. Alcohol is a toxin to the brain resulting in reduced intellectual function and memory loss, often long after a person returns to sobriety.
Alcoholism is a family disease. Spouses and children are victims as well as the drinker. Inattention to family members, absence from the home, hostility and volatility in relationships, domestic violence, separation and divorce are commonly associated with alcoholism. The financial consequences of purchasing alcohol, legal encounters, increased insurance rates and medical encounters can significantly impact a family, as can divorce.
The FAA programs for returning alcoholic pilots to flying duties highly encourage treatment of the family and participation of the family in the recovery process.
Alcoholism often involves the legal system. Traffic tickets are frequent warning signs of alcohol abuse. Speeding and other moving violations, even if not legally intoxicated, may be associated with alcohol use. From a legal perspective, there are three outcomes of alcohol abuse resulting in DUI?s and accidents. With lenient judges and persuasive attorneys, the alcoholism can be Covered Up. Less lenient judges and serious accidents may result in the alcoholic being Locked Up. An insightful support system will help the pilot get Sobered Up.
The FAA systematically checks the driver?s record of every pilot each time an application for a medical certificate is processed. Pilot?s are asked if they have any motor vehicle actions related to alcohol or drugs on the Airman?s Medical Application. Even those motor vehicle actions that are downgraded in court to some offense not mentioning intoxication are considered alcohol related. Reporting is required to the FAA Securities Division within 60 days of the action and to the Aeromedical Certification Division at every future medical application. Pilots who falsify the application face serious consequences against both their medical and pilot certificates.
Alcoholism affects co-workers and the company. Missed work or tardiness due to hangovers or blackouts requires others to cover for the alcoholic?s duties. Employers may have to use replacement pilots to meet the demands of the flight schedule. An unreliable pilot or mechanic strains working relationships. Errors in judgment and procedures can lead to costly damages to an aircraft. Hostility in the workplace results from irritability in social interactions, lack of professionalism, inattention to detail or inappropriate language and behavior.
The mental degradation due to alcohol use may manifest as training difficulties or failures due to inability to concentrate. Reputations may be damaged by customers encountering a surly, sloppy, or forgetful crewmember. The suspicion of alcohol on a crewmember?s breath is disastrous to a company. A positive alcohol test for a pilot can result in revocation of the medical certificate and possible suspension or revocation of all pilot certificates.
Alcoholism compromises aviation safety. Alcohol and other substances that affect the mind impair the ability to think clearly, react quickly, anticipate dynamic environments and handle complex tasks. Effective Crew Resource Management (CRM) activities are inhibited by the rigidity in decision-making and self-centered behavior of the alcoholic. Even the pilot who is completely sober is plagued by decreased mental function and abilities months after stopping drinking. The compromised abilities are often so subtle as not to be noticed, but remain very significant in the complex, multi-tasking world of aviation.
According to the FAA Civil Aeromedical Institute publication ?Alcohol and Flying?, over a seven year period, approximately 12% of all pilots in fatal general aviation accidents had measurable levels of alcohol in their blood at the time of their death. Multi-pilot aircraft have lower rates of fatal mishaps, as well as mishaps with alcohol in pilots? blood. What can not be measured are those pilots whose judgment was impaired form chronic alcohol effects on the brain, but did not have alcohol in their blood at the time of the mishap or near-mishap.
Our Company Does Not Have A Problem with Substance Abuse!
Maybe. As stated above, alcoholism in industry is often undiscovered, unrecognized and unreported. Additional well-meaning motivations in the aviation industry may be to ?protect? a pilot?s career and certificates by not reporting suspicions or actively concealing evidence of alcohol abuse.
The early signs of alcoholism are often ignored. Tardiness for work, particularly on Mondays or following holidays after heavy consumption, is common. Complaints of hangovers, headaches or fatigue are common, but non-specific. Errors in maintenance procedures or flight planning occur because of the lack of attention to detail and intellectual deterioration resulting for alcohol.
Afflicted individuals may miss deadlines and have very believable excuses. Denial is powerful and rationalization is the tool of denial.
Persons who do not have control of their lives frequently complain about their personal problems to anyone who will listen, such as a co-worker, crewmember, or bartender. Hostility and blaming others for problems is common. Fellow pilots may start to avoid trip pairing with the alcoholic for a variety of reasons. The inattention to detail may raise safety concerns or fears that the crew will suffer jointly for the errors of one. Hostility and complaining may make unpleasant company. Alcohol abuse erodes trust and confidence.
Later signs of alcoholism in the work place may arise when the individual tires to cover up evidence of heavy alcohol use. Strong aftershaves and colognes may disguise alcohol on the breath. Sometimes meals are eaten alone to hide the need for alcohol. When the individual can no longer hide the need for alcohol, trip layovers may include trips to the hotel bar or drinking ?a lot? at dinners. A hangover on the day of a flight is very bothersome, as is alcohol on the breath or on clothing.
Very late signs that cannot be denied or ignored include a positive drug or alcohol test or a mishap in which alcohol is detected. The consequences to the individual are disastrous in both circumstances. The consequences to the company can be severe in the later situation.
Alcoholism that is not effectively addressed affects the company in many realms. Initially, pilots may call in sick for trips at the last moment, putting the company at risk for unfulfilled flight requirements. Increased sick leave usage and requirements for replacement pilots drives up personnel costs, as does the reduced productivity and reliability of personnel abusing alcohol. When alcohol use compromises safety or results in errors, the company?s reputation can be damaged. All of these unfortunate circumstances results in lost revenue.
What To Do? ? Choices for the Company
Three possible actions exist for the company that has employees that may be afflicted by alcoholism or substance abuse. Each of the three choices has dramatically different strategies and outcomes.
The first choice represents the status quo for most companies. The status quo in many companies is no policy for recognition, no policy for treatment, no policy for assistance. This is equivalent to ignoring the possibility that some employees may be affected by alcohol or substance abuse / dependence. This strategy involves two big hopes. One, the company can ?Hope for the Best?; but what is ?the Best?? Perhaps it is that no employees will have any problems that affect the company, but the more likely outcome is that the problems will not rise to the level that they are obvious. The second big hope is the ?Hope that No One Else Notices.? The problem is that others do already notice, but again, the problems have not risen to a level that is obvious and adverse.
The second strategy has been adopted by a number of companies. This is the ?Zero Tolerance? approach of an organization that wants to appear as having no problems because it gets rid of the problems. Employees who are discovered, even if they initiate seeking help, are terminated. This approach seems to be cost-efficient to accountants and easily administered, but these are false impressions. This approach results in a ?hide-and-seek? atmosphere. Active concealment and protection of employees with problems causes disharmony and distrust. The problems still exist, but there is no route to seek help. The employee, co-workers and the company all suffer.
The last strategy involves a ?Proactive Approach?. Compassionate concern and constructive confrontation characterize the proactive approach. This is not to say that alcoholism is tolerated in the workplace. Rather, there must be firm standards and clearly defined consequences of choices the employee makes. As long as a mechanism exists for an employee or concerned coworkers to come forward and seek help without immediate negative consequences, alcoholism can be effectively treated and the workplace improved.
For pilots, the proactive approach requires another very important element. The pilot?s FAA certificates must be protected. Fortunately, the FAA has established a program that allows pilots to return to full duties after successfully completing a treatment program with the continued cooperation and monitoring by the company. The program has been immensely successful in the airline industry. The FAA is now seeking to include corporate aviation in a similar program. The goal is to improve aviation safety and protect pilots? health and careers.
Components of a Proactive Substance Abuse Program in Aviation
A proactive substance abuse program for pilots has many elements which are key to its success. Confidentiality and respect of privacy overlie each of the other elements, although there cannot be complete confidentiality. Knowledge of participation needs to be limited to those with ?a need to know? and those the pilot wants to inform.
A firm commitment for support of the program by management, usually involving the Employee Assistance Program (EAP), is critical to success. Without this support, the company falls into either the ?Ignore/Hope for the Best? approach or the ?Zero Tolerance? approach.
Non-punitive options for seeking help are essential to prevent alcohol and substance abuse from being driven underground. These options need to be accompanied by clearly defined, well publicized procedures for seeking help and obtain treatment if required. Consequences of each choice the pilot may make associated with seeking help also need to be clearly defined.
Treatment for substance abuse and dependence is intensive and expensive. Because pilots in treatment programs will not be flying during treatment and the initial phases of recovery, adequate medical insurance for treatment is very helpful. A sick leave policy that allows use of sick leave for treatment is also very helpful.
Treatment needs to be conducted by a credible facility with trained professionals committed to recovery of each client. Some treatment facilities skimp on duration of treatment, use of professionals in all phases of treatment and an extended aftercare program. These substandard programs waste money and are unacceptable to the FAA.
Relatively unique in alcohol treatment programs is the requirement for peer/fellow pilot active involvement in all aspects of the program. Peers not only may be involved with the identification and possibly the intervention of an afflicted pilot, but they are required by the FAA to be involved in a monitoring program for the alcoholic pilot who has been returned to flying.
Program Elements Overview
A written structure serves as the backbone of a proactive pilot assistance program. The written structure should include a mission statement that defines the goals of the program. Company policies should clearly be stated in the next part of the written structure. Finally, detailed written guidance should describe procedures for each participant in the program to follow. The written structure helps avoid variations that may undermine the program and allows new participants to refer to specific guidance, similar to a flight operations manual on an aircraft.
A treatment continuum insures that a comprehensive program is available to support the pilot seeking treatment as well as those that have completed treatment and are seeking to maintain sobriety. The treatment continuum is discussed in detail below. Key steps in this continuum are:
1) Identification of a potential problem;
2) Intervention for a specific individual;
3) Assessment of whether a problem truly exists by impartial, trained professionals;
4) Treatment, including aftercare, of individuals with problems;
5) Continuing monitoring of the recovering individual.
The next element is FAA medical certification. This process includes a careful review of all aspects of the treatment continuum. Certification by the FAA also includes a review of the monitoring program by the company, peers and medical professionals. Certification is not permanent, but subject to periodic review and documentation of continued sobriety and commitment to a 12-step program.
Education and training for all those involved in the program is an essential element for a successful program. Training needs to be conducted for specific groups directly involved in the pilot assistance program. These groups include EAP staff, supervisory/management personnel, chief pilots, professional standards personnel, peer monitors and possibly training staff if flight training is conducted by in-house pilots. Education of the entire pilot group and their families is important to know a program exists and to understand key elements of the program. Families may recognize substance abuse problems early and they need to know how to find assistance in addressing their concerns without jeopardizing the pilots? employment. Finally, regular promotion of the program is required to demonstrate commitment and to reinforce procedures for seeking help.
The last element is program evaluation. Similar to FOQA, regular evaluation of any assistance program with open, non-attributional input is critical for feedback leading to improvement.
A receptive climate within the company is a valuable asset in identifying the scope of alcohol related problems and to reducing the impact of alcohol on the company. Employees must know that a program exists, that the company supports employees seeking help and how to initiate the process of seeking help. Education is critical in this part of the continuum.
The one step in educating employees about the receptive climate of the company is publicizing the policy. Employees need to know the policy exists. They need to be reminded regularly, thus highlighting to commitment of the company to this program. Supervisors should include a review and status report regarding their alcohol programs in scheduled management meetings. Equally important is notification of the employee?s families. They are the first ones to be aware of problems. They need to know help exists within the company, and how to seek that help.
The EAP staff must know that they are responsible for a significant portion of the administration of the program. They must have reliable, qualified contacts in the community for providing care. They also need to be familiar with company policies and procedures through specific training of the unique requirements of programs for pilots.
The company, in conjunction with EAP and experts familiar with FAA requirements must clearly define a written protocol for providing assistance to pilots seeking help. The policy must be published and distributed widely. Absence of knowledge of a program within the company is tantamount to having no policy at all.
The overriding key to all phases of any policy allowing pilots to seek help for alcoholism is the expectation and confidence that their confidentiality will be respected by everyone involved. No absolute legal right similar to physician-patient privilege exists when dealing with non-physicians, even if the concern is a medical diagnosis. However, success of the program depends on discretion of those involved and limitation of knowledge/talk about an individual?s seeking help to the very small circle of people involved with a need to know. Undesired breaches of confidentiality will rapidly become widely known and sabotage any program.
Deciding to seek help for alcoholism is the most challenging step for the alcoholic. Assisting the alcoholic to reach this decision also presents the most difficult challenges for friends, supervisors and the company. The process of helping an alcoholic pilot who does not self initiate seeking help toward sobriety is termed ?intervention?.
There are two methods an alcoholic pilot may enter a program to treat the disease. First, the pilot may recognize the severity of the disease, as spontaneously seek treatment. Because of the power of denial in all addictive behaviors, self-initiated seeking of treatment usually follows a significant adverse medical, legal, or social event. In rare cases, a pilot may seek treatment prior to facing adverse consequences. The presence of a well-established and publicized program makes this method proceed smoothly.
The more common scenario is that despite adverse consequences, the alcoholic pilot denies the existence of any problem and refuses suggestions/pleas by concerned people to seek treatment. The intervention is the key to moving the pilot toward treatment.
The purpose of the intervention is to present two clear alternatives to the pilot: termination or evaluation and, if validated, treatment for the addictive disease. Ultimately, the final decision rests with the pilot. The intervention is a co-coordinated meeting, often mandated, with the pilot and significant people in the pilot?s life including management representatives, peers, family and possibly EAP staff.
Similar to the need for a flight plan prior to flying, an intervention requires careful planning and coordination of all of those involved. A carefully planned, well conducted intervention has a good chance of success. A poorly conducted intervention is nearly always doomed to failure. The ?five principles? of intervention include: concern, meaningful people, specific information, realistic alternatives and follow-up.
Each person involved must know exactly what information they will present to the pilot in the meeting. There must be a leader to insure each person has the opportunity to present key information, to moderate the emotionally charged atmosphere and to present the alternatives to the pilot.
Concerned compassion allows individuals participating in the intervention to present information in a non-judgmental manner. Observed behavior is not stated as immoral, or otherwise intentionally hurtful, nor is the information presented in a hostile challenging fashion. This will only influence an already tense situation. Rather, the pilot is presented with facts that have raised concern among meaningful people in the pilot?s life who want to help the pilot avoid further consequences, thus protecting the pilot?s health, family and job. Emotional reactions must be countered with calming responses of concerned compassion.
Constructive confrontation involves presenting specific facts to the pilot regarding observed behavior, preferably firsthand accounts by those involved in the intervention. Presenting the consequences of the alcoholic?s behavior, usually previously unknown to the pilot, adds strength to the intervention. Examples include stating when a fellow pilot may have refused a trip pairing because of discomfort due to alcohol use or the hidden fearful reaction of a child after seeing an alcoholic parent ignore them or flash out in anger.
The result of the intervention is that the pilot will choose one of two outcomes. The first, and desirable, outcome is that the pilot will agree to seek a professional evaluation for the possible alcoholism. The pilot must also agree to participate in a treatment program if the evaluation confirms a diagnosis of alcohol abuse or dependence. The evaluation and, if needed, treatment needs to be completed prior to returning to any duties with the company. There is no benefit to any delay between the intervention, evaluation and treatment. The company must agree, and the pilot must be clearly informed, that if the result of the evaluation does not support a diagnosis of alcohol abuse/dependence, the pilot will promptly return to flight duties.
The second alternative following an intervention is prompt termination. Without the ?carrot and stick? approach, the program has no enforcement power. Denial, delay and indecision will defeat the purpose of the program to make treatment available immediately to those who choose to recognize and manage their disease. The choice must be unequivocal, the action immediate. Follow-up of the pilot?s choice cannot be delayed. Either the pilot returns to flight duties, enters treatment or is terminated.
· Assessment and Evaluation
The intervention does not mean a foregone conclusion of a diagnosis of alcoholism exists. It only means that significant individuals are concerned that a problem may exist. Further assessment and evaluation is required before a definitive conclusion is reached. Professionals trained in the area of substance abuse conduct this phase of the program.
The assessment is generally conducted by a non-physician, known as a Substance Abuse Professional (SAP), with considerable experience and training in addictive behaviors. The assessment consists of interviews, completion of questionnaires and review of inputs from people participating in the intervention. The SAP may be someone on the company EAP staff or associated with an outside facility.
The SAP may find that the concerns of the people in the intervention are not justified or cannot be validated. In this case, the results of the assessment are relayed to the company supervisor/management and the pilot returns to work. Later assessments may be appropriate. Further interventions may be appropriate if further concerns arise or persist.
If the results of the assessment lead to a diagnosis of alcoholism, the pilot is referred for treatment. In cases when uncertainty or disagreement exists, a more formal evaluation by a physician and psychologist trained in addiction medicine is required. The evaluation involves a comprehensive battery of psychological and personality tests and an extensive interview. Often the interview will involve the spouse or family members who have the closest observations of behavior and recall of events.
The evaluation is expensive in the short term, but foregoing evaluation and treatment is much more costly in the long term.
The diagnosis of alcoholism, abuse or dependence will result in the loss of a pilot?s medical certificate. The program described in this paper provides a route for an expedited reinstatement of the pilot?s medical certificate.
Most assessments and evaluations confirm the concerns of the intervention and result in a referral for treatment. Treatment must be comprehensive and conducted by fully qualified professionals at facilities familiar with the disease. Some facilities do not have a program that result in a reasonable opportunity for long-term remission. These programs are not acceptable to FAA Aeromedical Certification authorities when a pilot later petitions for reinstatement of the medical certificate.
Ideally, treatment programs will include an extended impatient phase up to 28 days, where the pilot remains in a facility until the completion of treatment. Recent reductions in insurance coverage have virtually eliminated 28-day inpatient programs. More commonly the pilot will remain in a facility one to two weeks followed by an intensive outpatient phase of eight or more hours per day of group treatments supervised by professional staff and overseen by a physician certified in addiction medicine.
All treatment programs must require continuous sustained total abstinence. FAA medical certification is contingent on this requirement. Almost all acceptable programs use a 12-step method of recovery.
One element of the measure of recovery is a pilot?s progress through the 12 steps of a recovery program. At the time of discharge from a program, a pilot has often progressed to Step 3 or Step 4 of the 12 steps and will continue to ?work the program? in later phases of the recovery process.
Following discharge from an inpatient/intensive outpatient facility, the pilot enters an aftercare program and begins regular participation in Alcoholics Anonymous (AA) or a very similar program.
The aftercare phase involves several group meetings each week, of several hours duration led by a trained professional in substance abuse. The aftercare program usually lasts several weeks to months before beginning to taper in frequency to weekly meetings. These weekly meetings continue for one or more years to meet FAA criteria. The advantage of group meetings over individual sessions is the ability of the group to detect weaknesses in an individual?s progress in the 12 steps, to assist, and when necessary, to challenge an individual who appears to be struggling or slipping. The professional monitor documents progress in the program objectively and knowledgably.
Involvement with AA occurs simultaneously, with, but separately from, the aftercare program. AA meetings do not have a professional leader, but rather limits participation to those who share the addiction and share their feelings and experiences. Some AA meetings accept people having other addictions, such as gambling or narcotics, but this acceptance tends to dilute the benefit of the meeting which relies on shared, common experiences.
Some pilots have problems identifying with some members of diverse AA groups, such as those including teenagers, criminals or others who do not have a common background. Many pilots feel more comfortable in AA meetings of professionals, including physicians, attorneys, accountants, executives, etc. A subset of AA composed of only pilots meets around the country. The subset is called ?Birds of A Feather?. Many meetings are at cities with airline hubs or large flight operations allowing pilots traveling away from home to attend meetings with other alcoholic pilots.
The FAA prefers to see a minimum attendance of 90 AA meetings within the first 90 days from discharge from the inpatient/intensive outpatient phase of treatment. This may seem like an extremely difficult task to accomplish, but most cities have many meetings every day throughout the city. Pilots need to find a group they are comfortable meeting with regularly. Pilots also need to find a sponsor within the group they are comfortable speaking with daily.
The treatment phase of recovery from alcoholism never ends, even long after the pilot has returned to flight duties. Regular participation in AA, and having resources to contact immediately when confronted with challenges is essential to progressing through the 12 steps and maintaining sobriety. Continuous sustained and total abstinence from alcohol is mandatory.
As the pilot nears the point of petitioning the FAA for reinstatement of the medical certificate through the Special Issuance process, independent monitors of the pilots must be selected. The FAA requires a minimum of two monitors before considering reinstatement of a medical certificate. These monitors include a pilot and a company supervisor sponsor. They in turn report to the independent medical sponsor (IMS) who is also usually a Senior Aviation Medical Examiner.
The pilot peer sponsor is frequently designated by the pilot union if a union exists on the property. In non-unionized organizations, a trusted volunteer willing to commit to participation for two or more years is acceptable. Likewise, the company sponsor is also a volunteer with some supervisory/management responsibilities over the pilot. The FAA requires monthly meetings with the pilot and the two sponsors. In larger organizations, groups of pilots may meet together with the monitors in a single meeting. Both sponsors must make a monthly report on the progress of each pilot and the pilot?s continued sobriety. Additional information and examples of behavior reflecting the pilot?s recovery are welcome in the reports. The pilot is responsible for insuring the reports are completed and forwarded monthly to the independent medical sponsor.
The independent medical sponsor (IMS) is usually a FAA Aviation Medical Examiner who has attended the joint ALPA-FAA HIMS training seminar. Ideally, the IMS has some experience in addiction medicine. The IMS examines the pilot for any evidence of alcohol use, receives reports from peer and company sponsors, makes quarterly reports to the FAA and directs the frequency of no-notice alcohol testing during the FAA monitoring period. Most importantly, the IMS receives all reports from the pilot?s treatment, aftercare, and sponsors and uses this information in conjunction with personal observations, to assemble an aeromedical summary petitioning the FAA for a reinstatement of the pilot?s medical certificate. Following recertification, the IMS must submit the quarterly reports to the FAA annually or semiannually. If these reports are not submitted, or if the reports are unfavorable, the pilot?s Special Issuance medical certificate is in jeopardy.
FAA Medical Certification (Special Issuance)
As stated above, the IMS must collate complete records of all phases of treatment, sponsorship and examinations to support a petition for reinstatement of a medical certificate. Additionally, the pilot must undergo a complete assessment by a psychiatrist-psychologist team approved by the FAA to evaluate pilots. This assessment is conducted no earlier than 60 days after the initial sobriety date but may be much later.
One purpose of the psychological assessment is to determine if the previous consumption of alcohol has compromised any intellectual function necessary to safely operate an aircraft. Many pilots anxious to return to the cockpit seek to rush the timing of this assessment. Rushing is detrimental. The toxic effects of alcohol persist and gradually improve, similar to a slow healing wound. The longer the pilot wants to obtain the psychological tests after the sobriety date, the better the chances for favorable results.
The second purpose of the psychological assessment is to determine whether the pilot is making progress towards recovery and is committed to sustained recovery. The psychiatrist will assess the pilot?s plan for the future, resources for continuing support, tools available for difficult times ahead and support of significant others. While no assessment is foolproof, psychiatrists experienced in addiction medicine and aviation are very capable of seeing through the pilot who is simply ?checking the boxes? to try to get back to flying quickly. Patience and serenity in the pilot are good markers for commitment to a successful program of sustained recovery.
If the results of the psychological assessment are favorable, the IMS will conduct a physical examination, possibly including laboratory tests for evidence of alcohol use, prior to petitioning the FAA for reinstatement of the pilot?s medical certificate through the Special Issuance process. The IMS will compile an aeromedical summary outlining a detailed history of the pilot?s disease, route to evaluation, treatment program, continuing care program, employment circumstances, sponsors and progress in recovery. This summary, along with all medical records, is forwarded to the Federal Air Surgeon?s office in Washington DC for review by an FAA psychiatrist or a psychiatric consultant.
The FAA psychiatrist will review the records in detail prior to making a recommendation to the Federal Air Surgeon and FAA Aeromedical Certification Division. Often, the FAA psychiatrist will speak directly to the pilot, the psychiatrist, people involved in the treatment and continuing care program and the IMS as part of the review. The recommendation may be that more time must past to assess commitment to and progress in the recovery program. In favorable cases, the recommendation will be for granting a Special Issuance Authorization (SIA) for First Class medical certification. The FAA then sends the Special Issuance letter and medical certificate to the pilot.
Upon receipt of the new medical certificate and SIA letter, the pilot returns to the company for reinstatement to flight duties or training. There are usually no restrictions on what duties the pilot may perform with the SIA letter. The timeline for the entire process, from intervention to medical certification may be as short as four months, although usually is somewhat longer. Without the SIA under the sponsored alcohol program, the pilot may count on not returning to flying for at least two years of documented sobriety, but perhaps much longer.
The SIA letter will specifically outline periodic requirements of the pilot to maintain medical certification. The prime requirement is total, sustained abstinence from all alcohol and alcohol containing compounds (including cough syrups, ?non-alcoholic? beers, etc.). This abstinence is for the duration that a pilot holds a medical certificate, i.e., for an entire career.
Additional requirements include continued regular participation in a continuing care program, a 12-step program and meeting monthly with peer and company monitors. The monitors may ask for inputs from AA sponsors. The pilot is responsible for insuring reports for all of the monitoring meetings and summaries of the continuing care program are forwarded to the IMS quarterly. The IMS will make reports to the FAA either quarterly or semi-annually. The IMS may also direct no-notice drug and alcohol testing or laboratory testing to validate the pilot?s statement of abstinence. Testing conducted by the IMS as part of the Special Issuance process is not considered part of the DOT random testing program. Continued favorable reports from all of the persons involved with the pilot are necessary for maintaining the SIA and medical certificate.
Annually, the pilot will also have to obtain assessments from the psychologist and psychiatrist who did the pre-certification assessments. These reports are sent to the IMS, who in turn, sends them to the FAA for review in support of continuing the SIA and renewal of the medical certificate. This monitoring program will continue for at least two years. In many cases, monitoring may continue for many more years, particularly if there are risk factors for relapse or a weakness in the pilot?s continued commitment to a recovery program. Some pilots have been monitored for over 15 years.
If the FAA is satisfied that a pilot has made excellent progress in the recovery program and is at low risk for recurrence, the FAA may discontinue the requirement for monitoring and no longer require a SIA for medical certification. In these cases, the pilot resumes taking medical exams at the regularly scheduled intervals, although always reporting on the medical application that a diagnosis of abuse/dependence exists. The FAA will continue to require sustained, total abstinence as long as the pilot holds a medical certificate, even though the monitoring has been discontinued.
Relapses into drinking occur, although the rate among pilots going through the FAA mandated program is under 15% over a career. This rate is far lower than any other program in the country and is a direct result of the very involved approach of the FAA and significant people in the pilot?s career. The FAA will allow a pilot who has relapsed following a SIA for abuse/dependence to re-enter treatment with the opportunity for reinstatement of the medical certificate and SIA. The pilot?s application for the SIA is scrutinized very carefully and the FAA demands a longer observation period following initiation of treatment and prior to certification. Obviously, pilots recertified after a relapse are monitored for an extended period. Second relapses generally receive unfavorable reviews by the FAA, effectively ending a pilot?s flying career.
Program Benefits ? Pilots
The benefits to pilots of this very progressive program available to alcoholic pilots through the FAA touch nearly every area of a pilot?s life. The pilot?s health, fitness and longevity are improved. Financially, the costs associated with alcohol are reduced, though payment for the treatment and recovery programs, as well as the assessments, are potentially a burden.
As part of the recovery program, the pilot makes amends with those who have been hurt by the alcoholic behavior. Personal relationships heal following active steps by the pilot to apologize and forgive. The serenity that blossoms from a viable recovery program changes the manner that alcoholics deal with stress and adverse circumstances.
The recovering pilot is a safer pilot. Intellectual functions and judgment are improved. The pilot is more reliable and conscientious as well as easier to deal with in a cockpit crew environment.
Program Benefits ? Company
The company sees many tangible benefits to participating in a pilot?s recovery program and reaps many intangible benefits also. The pilot has improved productivity, reduced tardiness and missed assignments, and a decrease in costly sick leave utilization. These benefits directly affect the flight department?s financial picture. The program is a valuable benefit for recruiting and even allows the acceptance of fully qualified pilots in recovery. Training costs are reduced if pilots are not terminated immediately upon company knowledge of an alcohol problem. Sick leave use and the cost and inconvenience of hiring/training replacement pilots are also reduced.
The company with a program that is strict, but supportive, will reap benefits for its reputation for excellence in the business aviation community. The presence of a recovery program for pilots on the property may improve the liability profile of the company versus a company that ignores or drives alcoholism underground. Exxon paid substantial money for the Exxon Valdez incident because of the lack of a program available for alcoholic crewmembers.
Within the airline industry, initial studies of the HIMS program demonstrated a 900% return on investment for participating companies. Some airlines now state that their ROI is nearly double the initial figure as the program matures and gains wider acceptance. In addition to the financial bottom line, the real benefit to the business aviation community of similar programs would be safer, crews, safer, aircraft, safer operations and safer skies.
Results of Initial HIMS Study and DOT Testing Follow-up
Following the initial 22 months of the FAA-ALPA HIMS program, the HIMS participants submitted a report of the early results. In the two years prior to the HIMS program, the FAA received an average of eight petitions per year for medical certification following treatment for alcoholism. During the initial HIMS period, 79 petitions were submitted. Seventy six percent of petitions submitted through the ALPA Aeromedical office were approved. This amounts to an increase rate of seeking treatment of over 400% annually.
Since the initial HIMS study, the FAA has granted over 3,600 Special Issuance medical certificates to airline pilots following treatment for alcohol/drug abuse and dependence. The overall long-term abstinence rate exceeds 85%, by far the best in any industry.
In the early 1990?s, public demand resulted in the implementation of federally mandated DOT drug and alcohol testing programs. Despite the aggressive testing and severe consequences of a positive test, studies have shown that the testing does not deter the onset of addiction nor the degree of abuse/dependence problems in the industry.
Further analysis demonstrates that early intervention prior to job decrement is essential to flight safety. A program of non-judgmental treatment with the opportunity to have a job reinstated with successful treatment and monitoring is the only proven method of reducing untreated alcohol abuse/dependence in the aviation industry. When there is no system established to constructively confront them, 80% of affected of alcoholic pilots will go untreated. When chemical dependency progressed without therapeutic intervention, it could manifest itself by on-duty withdrawal seizures, by violation of governmental or company rules regarding alcohol consumption, or by the insidious effects of hangovers while flying. Any of these situations could make the company and pilot culpable.
The initial HIMS study conservatively calculated a 9:1 return on investment for airlines instituting a program of alcohol treatment. As the program has matured, some airlines are estimating a 16:1 return on investment as the familiarity with the program grows and more HIMS trained union and management personnel were on the property. Health plans and random testing, although good in themselves, cannot substitute for a peer-driven, FAA-specific, pilot program integrated in their fabric. In every case, airlines participating in a program have shown that involvement by the company has resulted in significant costs savings, as well as improvement in health and safety.
Philosophy - Establishing a Corporate Aviation Assistance Program
Significant annual investments are made in pilot training, aircraft maintenance and avionics in support of aviation safety. A commitment to pilot health, optimum performance and safe operations is equally important in the world of aviation safety. Planning for excellence in all phases of flight operations is possible. With a new FAA interest in bringing the extremely effective model of the airline HIMS program to business and corporate aviation, a unique opportunity exists for corporate flight departments committed to aviation safety in all aspects of their operations. To add to the very insightful motto of Flight Safety International, an investment in corporate aviation assistance program in the company recognizes ?The best safety device in any aircraft is a well-trained [and healthy] pilot.?
Although many individual airline pilots have testimonials regarding how the HIMS program saved their careers, their families and their lives, statements from leaders in the aviation industry speak loudly about the benefits of a commitment to constructively assisting pilots facing the challenges of alcohol abuse and dependence.
J. Hart Langer, Vice President for Operations, United Airlines, stated, ?Our joint company/ALPA/EAP effort has saved dollars, careers and lives. Professional airmen and medical experts have worked together at United for over twenty years in this compassionate business of pilot recovery.?
Walter Coleman, President of the Regional Airline Association recognizes ?The HIMS program is noble in its objective and exceptional for its effectiveness.?
In a reflection of the FAA philosophy, Jon L. Jordan, MD, JD, FAA Federal Air Surgeon advises ?In terms of aviation safety and prolonging the careers of airmen, there is no program that has been more universally successful than that established through HIMS.?
Alcohol and drug abuse exists in all aspects of aviation. Ignoring the issue has a broad range of negative consequences for pilots, companies, clients and aviation safety. Using a peer-driven, company-supported program of early intervention and compassionate treatment significantly reduces the effects of this disease. The FAA has established a mechanism for early medical recertification of pilots successfully participating in a treatment and recovery program. Company support is the key to success. Commitment to a corporate aviation assistance program for pilots will enhance aviation safety and save dollars, careers, relationships and lives.