Part 61 of the Federal Aviation Regulations requires all airmen performing pilot duties to hold a current, valid medical certificate [61.3(c)]. Glider and balloon pilots are excepted and only require a personal statement of freedom from known medical defects that would adversely affect the safe operation of those types of aircraft. The duration of each class of medical certificate and type of medical certificate required for specific pilot operations is also defined in FAR Part 61.23. First Class medical certification, required for captain and some international first officer duties, is valid until the last day of the sixth month following the date of issuance of the medical certificate. Second Class certification, required for commercial operations, is valid for 12 months. The duration of Third Class certification, required for private and recreational operations, varies with the age of the pilot at the time of application. Pilots who apply for medical certification on or after their 40th birthday will hold a certificate valid until the end of the 24th month after their applications. Those who apply for certification prior to their 40th birthday are eligible for a certificate valid for 60 months. This certificate is valid for U.S. airspace only after the 24th month to comply with ICAO regulations.
In most cases, a higher class of medical certificate automatically lapses to the next lower class of certificate and is valid for the duration authorized for each class based on the date of application. For example, a 42 year old pilot issued a First Class medical certificate on December 7, 1999 would be eligible for first class privileges through June 30, 2000. Without taking another medical examination, the certificate would be valid for second class privileges through December 31, 2000 and third class privileges through December 31, 2001. Some pilots granted Special Issuance medical certificate for significant medical conditions may have a time-limited medical certificate that does not automatically lapse to a lower class. These are discussed below.
Medical Standards and Policy Making
Part 67 of the FARs defines medical certification standards and Special Issuance Authorizations. Fifteen specific medical conditions are specified as disqualifying, although other sections of regulation gives wide latitude to the FAA and designated aviation medical examiners (AMEs) to defer medical certification until additional information about medical conditions is provided to the FAA Aeromedical Certification Division (AMCD), the FAA Office of Aviation Medicine or the Federal Air Surgeon. The fifteen mandatory disqualifying medical conditions are angina; coronary heart disease that has been treated or, if untreated, has been symptomatic or clinically significant; cardiac valve replacement; permanent cardiac pacemaker; cardiac replacement (heart transplant); psychosis; bipolar disorder; personality disorder that is severe enough to have repeatedly manifested itself by overt acts; substance abuse or dependence (drugs or alcohol); epilepsy; disturbances of consciousness without satisfactory explanation of cause and transient loss of control of nervous system function without satisfactory explanation of cause. Other conditions are automatically disqualifying but not listed such as use of psychoactive medication (such as antidepressants) or use of an Automatic Internal Cardiac Defibrillator.
The Guide to Aviation Medical Examiners contains much more specific information on whether medical conditions require denial of medical certification or deferral of the medical application to the AMCD. The Guide also gives considerable leeway for AMEs to issue a medical certificate to pilots with potentially disqualifying conditions if appropriate documentation is provided at the time of application. The pilot?s treating physician should provide the documentation rather than the AME, unless they are the same individual. Pilots with medical problems are strongly encouraged to bring complete documentation of their treatment to an AME who is willing to call the FAA Regional Flight Surgeon or AMCD to obtain clearance to issue the certificate, if appropriate. This will avoid potentially lengthy delays in receiving the certificate and reduce the workload at the very busy AMCD.
Special Issuance Authorization (SIA) certification for disqualifying medical conditions is authorized by Part 67.401 of the FARs. A number of conditions require SIA letters from the AMCD or Federal Air Surgeon. These include the fifteen mandatory disqualifying conditions and any medical problems that are not a stable condition or requires periodic evaluation to assure the FAA that the pilot is not at significant risk for a safety-jeopardizing deterioration of the condition for the valid duration of the authorization. Examples include Parkinson?s disease, successfully treated cancer, HIV, cardiac arrhythmias and asthma on medication. Most of the fifteen mandatory conditions are eligible for SIA once stable, except for heart transplant or psychiatric conditions requiring regular medication. A SIA letter will list specific testing and the frequency required to obtain a renewal of the authorization. The SIA letter usually is mailed to the pilot with a SIA certificate that looks identical to the regular medical certificate with the exception of a signature from the AMCD Manager and a time restriction.
Special Issuance medical certificates frequently carry a restriction on the duration of the medical certificate. Such a restriction might read "Not valid for any class of medical certificate after June 30, 2000." The valid duration of SIA certificates is usually six or twelve months. In some cases, the valid duration of the SIA letter may be six months longer than the pilot?s medical certificate. These cases will limit the validity of the medical certificate to six months, but authorize the AME to again issue a new SIA medical certificate six months later with a new examination and submission of required testing and evaluations. Again, the new SIA medical certificate will have a time restriction on it.
FAA Medical Application and Waiver Statistics ? 1998
The AMCD located in the Civil Aeromedical Institute (CAMI) at the FAA Campus in Oklahoma City processes all medical applications, "waivers", and Special Issuance medical certificates. The Federal Air Surgeon?s office in Washington, D.C. may also become involved in certain pilot medical certification decisions.
The mailroom at the AMCD receives about 2,000 pieces of mail per day including a daily average of 1,235 medical applications seven days a week.
Of the 450,612 medical applications received by the AMCD in 1998, only 6,873 were given General Denials (disqualified) or 1.5% of total applications. Included in the General Denials are 6,074 denials because the airman failed to provide information requested by the FAA or did not pursue the application further. Thus, 89% of the airmen receiving denials may have been certified if they had submitted further documentation to the FAA. The Federal Air Surgeon issued only 799 (0.2%) Final Denials, or disqualifications after submission of all required information. Appeals to the NTSB following Final Denials resulted in thirteen subsequent issuances of medical certificates.
Overall, the FAA is comparatively lenient in waivering conditions for medical certification, particularly when compared to the military or the Joint Aviation Authority (JAA) of Europe. The FAA granted 8,189 authorizations for Special Issuance in 1998. Additionally, many other pilots received eligibility letters for medical conditions that require reporting and clearance, but do not require SIA. Examples include high blood pressure on medication, kidney stones and glaucoma. Pilots with other stable conditions that did not meet FAA medical standards, such as unilateral deafness, color vision deficiencies and monocularity received Statements of Demonstrated Ability (SODA). The SODA authorizes an AME to issue a medical certificate, despite not meeting standards, without requiring periodic reports from treating physicians. The FAA may require the pilot to complete a medical flight test or simulator evaluation with a FAA Inspector prior to receiving a SODA.
Recent AMCD Changes - Computerized Medical Records
The FAA AMCD is responsible for processing all airmen medical applications and determining eligibility for medical certification. As noted above, the workload based on the number of medical applications received each year is tremendous. Approximately 50% of all submitted medical applications require additional review for incomplete or incorrect information entry by pilots or AMEs. This additional review significantly increases the AMCD workload and slows processing of applications, thus adding to the frustration of pilots who may have had their medical certificates deferred at the time of their application.
As of October 1, 1999, the AMCD instituted dramatic changes that are designed to improve services significantly. The transition process is expected to last into mid-2000. The new changes should improve ability to track the status of pilot files at the AMCD, speed certification decisions, aid in accessing information previously submitted by the pilot, be Y2K compliant and allow better customer service to pilots and AMEs. Two key elements will support this new system, a real-time online submission of medical applications by AMEs and a paperless electronic filing system for pilot records. The new systems are called the Airman Medical Certification System (AMCS) and Document Imaging Workflow System (DIWS).
Airman Medical Certification System (Internet Based)
The online submission of airman medical applications began on October 1, 1999 using a system called Internet based Airman Medical Certification System (AMCS). AMEs are required to submit application through an online web connection to a secure server (128 bit) at the FAA. The application is transmitted in real-time to the AMCD. Additional information mailed to the AMCD will be added to the pilot?s electronic medical file by scanning the documents into the file on arrival at AMCD. Previously, the AMCS was a computer (not Internet) based system available in AMEs offices without a direct link to the AMCD.
Pilots? privacy is protected by restricting access to medical records to physicians and legal reviewers at the FAA. The AME currently can only access the pilot?s demographic information, not medical information from previous applications, through AMCS/DIWS. Future versions may allow AMEs access to additional information only if given an authorization code by the pilot.
The transition to the online AMCS system has highlighted several difficulties noted by AMEs that the FAA is attempting to correct. Access to the AMCD secure server and its redundant backup has not always been available during office hours or even after hours. The time for completing the online application takes longer than the previous AMCS. Modem speed and available transmission speed through the AMEs Internet Service provider also affects submission time. Until electronic signature technology is refined, the AME is still required to submit a paper copy of the application with an original signature. Unlike the previous version of AMCS, the new AMCS allows the AME to issue a medical certificate even if information submitted is outside the FAA standards. Some AMEs have had problems reviewing information on previously submitted pages of the application. The AMCD is actively working on corrections to the system. The DIWS Frequently Asked Questions section on the CAMI page may assist pilots and AMEs with questions about the new system.
Document Imaging Workflow System (DIWS)
The second key component is the DIWS electronic medical record and filing system of AMCD. All medical information will be scanned into the pilot?s file and catalogued by type of information. Certification personnel at the FAA will be able to review all records on a computer screen instantaneously, enter a certification decision into the computerized record and have that result immediately available to customer service personnel responding to telephone inquiries by pilots and AMEs. The current system requires several weeks to several months for the pilot to receive notification of the results of a deferred medical application.
The rate-limiting step of the new DIWS system will be scanning paper copies of medical records into the electronic filing system. FAA personnel previously assigned to filing duties can be reassigned to perform the scanning function to speed processing of the hundreds of medical records received daily in the mailroom. While transitioning from the previous paper files to the scanned electronic files, delays in handling cases at the AMCD are occurring. The backlog of paper files awaiting scanning in enormous. Special Issuance files which are very extensive will only have information from the last two applications forward scanned since each application has complete updated information. Until this filing backlog is reduced, hopefully by mid-2000, the AMCD?s ability to track old files and respond quickly to customer inquiries will be reduced. The AMCD is requesting its employees and contractors work overtime until the backlog is eliminated and taking other steps to speed processing time.
The overall result of this modernization program should be rapid aeromedical certification decisions and improved customer service to pilots and AMEs. Until the modernization is complete, patience and complete documentation of medical conditions is essential.
The AMCD Manager is Dr. Warren Silberman. He has oversight on all operations and has four physicians to review all cases. These physicians share the case review workload and divide cases into branches depending on the nature of the medical condition. In addition to review of routine medical conditions, they are responsible for reviewing and making a certification decision on each of the nearly 9,000 Special Issuance Authorizations and 7,000 General Denials, averaging 75 cases per work day for the Division that requires special handling and review.
The AMCD also uses non-physician "legal reviewers" who check each of the nearly 2,000 medical applications received every workday. The legal reviewers write eligibility letters for approved medical conditions or request additional medical information for incomplete medical applications or insufficient medical documentation. There are about 20 legal reviewers who divide incoming records alphabetically for processing.
"Waivers" - Medical Certification Review
Assuming the pilot?s AME has issued a medical certificate appropriately and the application is complete, the pilot should not expect to receive any correspondence from the AMCD if there are no significant medical conditions. Pilots who have new medical conditions requiring reporting to the FAA should provide documentation to the AME. Pilots issued a medical certificate by the AME will receive an "Eligibility Letter" from the AMCD at a later date. The eligibility letter acknowledges the pilots? privileges of their medical certificate, may list future reporting requirements and warns the pilot not to operate an aircraft if adverse changes in the condition occur (Part 61.53). All correspondence that is generated from the AMCD associated with significant medical conditions will have at least one identification number at the top, a PI# and/or MID#. Future correspondence to and from the AMCD should use these numbers to speed case management. The numbers are permanently assigned and should not change.
For cases requiring physician review and approval prior to flying, several possibilities exist. In straightforward cases involving conditions with well-defined criteria for eligibility, one of the AMCD physicians can make a certification decision. More complicated cases may be decided by a conference among all of the AMCD physicians, including the Manager, after presentation of all required medical data.
Several types of cases are determined after review of specialist physicians outside the AMCD. Specific cases, most commonly neurologic and psychiatric, may be forwarded to outside unpaid consultants who are national experts in their fields. The information is copied at the AMCD and mailed to the consultant who is asked to make a certification recommendation to the AMCD within 60 days. The consultant?s recommendation is returned to the AMCD for a certification decision and letter. The entire consultant review process may take three to four months. Occasionally, consultants may visit the AMCD to review multiple cases, usually shortening the review process
Pilots undergoing heart surgery and requesting First or Second Class medical certificates will have their cases reviewed by a panel of cardiologists who meet at the AMCD every two months for two days. The composition of the panel changes at each meeting. The panel recommends a certification action to the AMCD which then either grants a Special Issuance Authorization or issues a General Denial. Pilots with cardiac conditions requesting restricted Second Class or full Third Class privileges have their cases reviewed by a visiting cardiology consultant to the AMCD. Again, a FAA physician makes the ultimate certification decision.
Occasionally, some cases may be sent to several consultants or be presented to a FAA internal panel via teleconference. Physicians from the AMCD, the Regional Flight Surgeons and the Federal Air Surgeon?s staff review complex cases for certification decision. The cases usually involve potential policy changes, very unusual medical circumstances or novel treatments. Outside consultants may also participate. Favorable certification decisions usually result in a Special Issuance medical certificate.
Denial of Medical Certification
Pilots issued a General Denial have 30 days to appeal the Denial to the Federal Air Surgeon. Reversals of these Denials are rare, unless new and favorable medical information is presented. Unfavorable certification decisions to appeals or failure to appeal will result in a Final Denial and result in the FAA?s demand to return any previously held medical certificate.
Final Denials may be appealed to the NTSB. The process is generally lengthy and expensive, as it moves from the medical arena to the legal system. Of the 799 Final Denials issued in 1998, only 13 (1.5%) were subsequently granted certificates by the NTSB. Ultimately, appeals can be made through the U.S. Court of Appeals to the Supreme Court.
Pilots receiving denials may always request reconsideration through medical channels by submitting new medical information about their condition. This is generally a less expensive and time-consuming avenue than a legal appeal. The chances for success are somewhat greater also.
Overall, the FAA medical certification process allows pilots with a wide variety of medical conditions to fly. The medical "waiver" process takes some time for adequate review by aeromedical experts to determine safe operation of an aircraft will not be compromised by these conditions. Adequate documentation of medical conditions and treatment is necessary for appropriate review. The process favors the pilot and Final Denials of medical certificates are unusual. Improvements to the FAA Aeromedical Certification Division will hopefully speed the certification process and improve service to pilots.
For confidential aeromedical certification information, assistance and rapid submission of medical waiver requests to the AMCD by board certified aerospace medicine physicians, contact Virtual Flight Surgeons for a Private Consultation.