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United States Government Accountability Office: 
GAO: 

Aviation Safety: 

FAA Should Improve Usability of its Online Application System and 
Clarity of the Pilot's Medical Form: 

Aviation Safety: 

Report to Congressional Committees: 

April 2014: 

GAO-14-330: 

GAO Highlights: 

Highlights of GAO-14-330, a report to congressional committees. 

Why GAO Did This Study: 

FAA developed its medical standards and pilot's medical-certification 
process to identify pilot applicants with medical conditions that may 
pose a risk to flight safety. The Pilot's Bill of Rights (P.L. 112-
153) mandated GAO to assess FAA's medical certification standards,
process, and forms. 

This report addresses: (1) FAA's medical standards, policies, and
certification processes, along with medical experts' views on them, and
(2) steps that FAA could take to promote private pilots' understanding
of its medical requirements. GAO reviewed statutes, regulations, FAA
documents, and interviewed officials from FAA, NTSB, pilot associations,
and 20 aviation medical experts primarily identified by the National
Academies' Institute of Medicine. Experts were selected based on their
type and depth of experience, including recognition in the aerospace-
medicine professional community. GAO also interviewed FAA's medical 
certification division and evaluated the usability of FAA's online 
application system and the clarity of its application form against 
federal writing guidelines and best practices in website usability. 

What GAO Found: 

Aerospace medical experts GAO interviewed generally agreed that the 
Federal Aviation Administration's (FAA) medical standards are 
appropriate and supported FAA's recent data-driven efforts to improve 
its pilot medical-certification process. Each year, about 400,000 
candidates apply for a pilot's medical certificate and complete a 
medical exam to determine whether they meet FAA's medical standards. 
From 2008 through 2012, on average, about 90 percent of applicants
have been medically certified by an FAA-designated aviation medical 
examiner (AME) at the time of their medical exam or by a Regional 
Flight Surgeon. Of the remaining applicants, about 8.5 percent have 
received a special issuance medical certificate (special issuance) 
after providing additional medical information to FAA. Approximately 
1.2 percent were not medically certified to fly. According to an 
industry association, the special issuance process adds time and
costs to the application process, in part, because applicants might not
understand what additional medical information they need to provide to 
FAA. Officials from FAA's medical certification division have said 
that technological problems with the aging computer systems that 
support the medical certification process have contributed to delays 
in the special issuance process. FAA's medical certification division 
has identified about 50 potential technological enhancements to its 
internal computer systems that support the medical certification 
process, of which about 20 have been identified as high priority, but
the division has not yet implemented them or developed a timeline to 
do so. By developing a timeline to implement the highest-priority 
enhancements, FAA would take another step toward expediting the 
certification process for many applicants hoping to obtain a special 
issuance. FAA recently established a data-driven process using 
historic medical and accident data that authorizes AMEs to
certify a greater number of applicants with medical conditions who had 
previously required a special issuance. Officials expect this effort 
to allow more applicants to be certified at the time of their AME 
visit and to free resources at FAA to focus on applicants with higher-
risk medical conditions. 

GAO's analysis and medical experts' opinions indicate that FAA could 
improve its communication with applicants by making its online 
application system—-part of FAA's internal computer systems discussed 
above—-more user-friendly and improving the clarity of the medical 
application form. Specifically, GAO found that the online application 
system requires applicants to scroll through a lengthy terms-of-
service agreement and does not provide clear instructions, and that the
application form contained unclear questions and terms that could be
misinterpreted by the applicant. FAA could enhance its online 
application system by using links to improve navigability of the 
system and providing information that is more useful to applicants—-
for example, links to information about the risk that specific medical 
conditions pose to flight safety and any additional medical 
information applicants with those conditions would need to provide to 
FAA. FAA could also improve the clarity of its medical application 
form by incorporating guidelines established in FAA's Writing 
Standards, including shorter sentences and paragraphs, active voice, 
and clear terms and questions. These clarifications could not only aid 
an applicant's understanding of the medical standards and 
requirements, but also may result in more accurate and complete 
information provided by applicants to better inform FAA's 
certification decisions. 

What GAO Recommends: 

GAO recommends that FAA (1) develop a timeline for implementing
high-priority technological improvements to the internal computer
systems that support the medical certification process, and (2) enhance
the online medical-application system by clarifying instructions and 
questions on the form and providing useful information. The Department 
of Transportation agreed to consider the recommendations. 

View [hyperlink, http://www.gao.gov/products/GAO-14-330]. For more 
information, contact Gerald L. Dillingham, Ph.D., at (202) 512-2834 or 
dillinghamg@gao.gov. 

[End of section] 

Contents: 

Letter: 

Background: 

Experts Generally Agreed with FAA's Medical Standards and Supported 
FAA's Move toward a Data-Driven Approach to Its Certification Process: 

FAA Could Enhance its Online Application System and the Clarity of its 
Medical Application Form for Private Pilots: 

Conclusions: 

Recommendations for Executive Action: 

Agency Comments: 

Appendix I: Objectives, Scope, and Methodology: 

Appendix II: Summary of Selected FAA Medical Standards: 

Appendix III: Selected FAA Training Programs for AMEs and Pilots in 
Aerospace Medicine and Communication Tools: 

Appendix IV: FAA Form 8500-8 (Medical Application Form): 

Appendix V: GAO Contact and Staff Acknowledgments: 

Tables: 

Table 1: Frequency of Medical Certification Requirement and 
Distribution of Pilots by Medical Class (2011): 

Table 2: List of Medical Experts: 

Figures: 

Figure 1: Overview of FAA's Medical Certification Process: 

Figure 2: Screenshot Showing Small Window through which the Reader 
Must Scroll Pages of Information: 

Abbreviations: 

AASI: AME Assisted Special Issuance (see below for AME): 

ALPA: Air Line Pilots Association: 

AMCD: Aerospace Medical Certification Division: 

AME: Aviation Medical Examiner: 

AMSIS: Aerospace Medicine Safety Information System: 

AOPA: Aircraft Owners and Pilots Association: 

CACI: Conditions an AME Can Issue: 

CAMI: Civil Aerospace Medical Institute: 

DIWS: Document Imaging Workflow System: 

FAA: Federal Aviation Administration: 

FDA: Food and Drug Administration: 

EAA: Experimental Aircraft Association: 

ECG: electrocardiogram: 

ITDM: insulin-treated diabetes mellitus: 

MOU: memorandum of understanding: 

NTSB: National Transportation Safety Board: 

OMB: Office of Management and Budget: 

SMS: Safety Management System: 

SODA: Statement of Demonstrated Ability: 

SSRI: selective serotonin reuptake inhibitors: 

[End of section] 

United States Government Accountability Office: 
GAO:
441 G St. N.W. 
Washington, DC 20548: 

April 8, 2014: 

The Honorable John D. Rockefeller IV: 
Chairman: 
The Honorable John Thune: 
Ranking Member: 
Committee on Commerce, Science, and Transportation: 
United States Senate: 

The Honorable Bill Shuster: 
Chairman: 
The Honorable Nick J. Rahall II: 
Ranking Member: 
Committee on Transportation and Infrastructure: 

House of Representatives: 

The primary mission of the Federal Aviation Administration (FAA) is to 
ensure a safe and efficient flying environment. As part of its 
mission, FAA oversees the medical certification of about 600,000 
pilots[Footnote 1] to certify that they meet FAA's medical standards 
and are physically and mentally fit to fly. According to FAA 
officials, most applicants for a medical certificate meet FAA's 
medical standards and are medically certified after completing a 
physical exam by a FAA-designated physician. However, for applicants 
with a disqualifying medical condition, FAA's Federal Air Surgeon may, 
on a case-by-case basis, authorize a special issuance medical 
certificate (special issuance) for a specified period. An 
authorization for a special issuance requires the applicant to show to 
the satisfaction of the Federal Air Surgeon that the required 
operations can be performed without endangering public safety during 
the period of the special issuance. Medical conditions that generally 
disqualify applicants from medical certification to fly include 
certain heart conditions, diabetes, epilepsy, impaired hearing or 
vision, psychosis, drug and alcohol dependence, and also generally any 
disease, defect, or treatment that could prevent a pilot from safely 
operating an aircraft.[Footnote 2] About 10 percent of applications--
nearly 40,000 a year--may require, among other things, further medical 
evaluation, medical flight testing, or submitting additional 
documentation that can add time to the certification process. However, 
through the special issuance process, FAA has allowed some pilots to 
fly for a specified period with heart transplants, permanent cardiac 
pacemakers, and insulin-treated diabetes mellitus, among other 
conditions that would otherwise disqualify pilots from flying. 

The Pilot's Bill of Rights mandates that GAO assess FAA's medical 
certification process and the associated medical standards and 
forms.[Footnote 3] This report discusses: 

* FAA's medical standards and certification processes, along with 
medical experts' views on them, and: 

* steps that could be taken to promote private pilot applicants' 
understanding of FAA's medical requirements, including potential 
revisions to the medical application form.[Footnote 4] 

To address our objectives, we commissioned the Institute of Medicine 
of the National Academies to identify experts knowledgeable about 
aviation medicine.[Footnote 5] From the list of 24 experts identified 
by the National Academies, seven experts were either unavailable, had 
concerns over their ability to respond to the questions because of 
their unfamiliarity with FAA's medical certification program, or had a 
conflict of interest, and we added three experts recommended to us, 
for a total of 20 aviation medical experts. We conducted semi-
structured interviews of the experts to solicit their views on FAA's 
medical standards, the medical application form, and FAA's 
communication with physicians and pilot applicants. We also 
interviewed officials from FAA, and we visited the Civil Aerospace 
Medical Institute (CAMI) in Oklahoma City to interview representatives 
of FAA's Aerospace Medical Certification Division (AMCD) about FAA's 
medical standards, the medical application form, and FAA's methods for 
communicating pilot medical-certification information with physicians 
and pilot applicants. In addition, we interviewed officials from the 
National Transportation Safety Board (NTSB), representatives from two 
pilot associations, and representatives from the American Diabetes 
Association.[Footnote 6] We also received written responses from three 
regional airline representatives and two aviation medical associations 
regarding their views on FAA's current medical standards, the clarity 
of the medical form, and FAA's efforts to provide information to 
pilots and pilot applicants.[Footnote 7] Further, we analyzed FAA's 
Form 8500-8 (medical application form) and MedXPress.faa.gov (FAA's 
online application system), against the federal government's plain 
language and website usability guidelines. (See app. I for further 
information on our scope and methodology, including a list of medical 
experts we interviewed.) 

We conducted this performance audit from January 2013 through April 
2014, in accordance with generally accepted government auditing 
standards. Those standards require that we plan and perform the audit 
to obtain sufficient, appropriate evidence to provide a reasonable 
basis for our findings and conclusions based on our audit objectives. 
We believe that the evidence obtained provides a reasonable basis for 
our findings and conclusions based on our audit objectives. 

Background: 

According to FAA officials, FAA's medical certification requirement 
was established to prevent or mitigate the effect of various medical 
conditions that present an undue risk to the safety of pilots, 
passengers, or others.[Footnote 8] While most general aviation 
accidents are attributed to pilot error involving a loss of aircraft 
control, according to information provided by NTSB,[Footnote 9] 
medical causes were a factor in approximately 2.5 percent of the 
accidents from 2008 through 2012.[Footnote 10] By ensuring that 
applicants meet medical standards, FAA aims to reduce the likelihood 
of incapacitation of a pilot due to a medical cause.[Footnote 11] 

Federal regulations establish three classes of medical certification 
that correspond to the types of operations that pilots perform. 
Airline transport pilots who serve as pilots in command of scheduled 
air-carrier operations must hold first-class medical certificates. 
Pilots who fly for compensation or hire generally hold second-class 
medical certificates. Private pilots hold third-class medical 
certificates. (See table 1.) Depending on their age and the class of 
medical certificate sought, pilots must renew their medical 
certificate periodically, from every 6 months to every 5 years (e.g., 
commercial pilots--generally those needing first-or second-class 
medical certificate--must have their medical certificate updated more 
frequently than private pilots). After obtaining a medical 
certificate, and between renewal periods, pilots are prohibited from 
performing pilot operations when they know or have reason to know of a 
medical deficiency that would make them unable to fulfill their pilot 
operation.[Footnote 12] 

Table 1: Frequency of Medical Certification Requirement and 
Distribution of Pilots by Medical Class (2011): 

Class of certificate: First class (commercial); 

Age: More than 40 years of age; 
Frequency: Every 6 months; 
Approximate percentage of pilots per class: 8.4%. 

Age: Less than 40 years of age; 
Frequency: Every year; 
Approximate percentage of pilots per class: 12.4%. 

Class of certificate: Second class (commercial); 

Age: More than 40 years of age; 
Frequency: Every year; 
Approximate percentage of pilots per class: 3.3%. 

Age: Less than 40 years of age; 
Frequency: Every year; 
Approximate percentage of pilots per class: 11.8%. 

Class of certificate: Third class (private); 

Age: More than 40 years of age; 
Frequency: Every 2 years; 
Approximate percentage of pilots per class: 30.8%. 

Age: Less than 40 years of age; 
Frequency: Every 5 years; 
Approximate percentage of pilots per class: 33.4%. 

Source: GAO analysis of FAA data from 2011 Aerospace Medical 
Certification Statistical Handbook. 

[End of table] 

In the fiscal year 2014 budget submission, FAA estimated that its 
Office of Aerospace Medicine would need about $56.1 million in 
funding--about 4.7 percent of the total Aviation Safety budget--to 
carry out its mission. To assist in the nearly 400,000 medical 
evaluations of pilots and new applicants[Footnote 13] each year, FAA 
designates medical certification authority to approximately 3,300 
private physicians, or Aviation Medical Examiners (AMEs). The AMEs 
review applicants' medical histories and perform physical examinations 
to ensure that applicants meet FAA's medical standards and are 
medically fit to operate an aircraft at the time of their medical 
exam. Although AMEs are not FAA employees, they are trained in 
aviation medicine by the FAA and entrusted to make medical eligibility 
determinations for the majority of applicants, on behalf of the FAA. 
In order to become an AME and be authorized to administer medical 
exams, FAA requires AMEs to complete online courses in clinical 
aerospace physiology and medical certification standards and 
procedures before attending a one-week basic AME seminar. AMEs must 
also complete at least 10 pilot medical exams each year and a 
subsequent refresher courses every 3 years.[Footnote 14] 

All applicants for medical certificates and renewals follow a similar 
process. Applicants begin the medical certification process by 
completing Form 8500-8, Application for Airman Medical Certificate or 
Airman Medical & Student Pilot Certificate (medical application form) 
in MedXPress (online application system). For applicants with 
disqualifying medical conditions or for those who do not meet FAA's 
medical standards, the AME must defer the applicant to FAA to 
authorize a special issuance. The special issuance process may require 
additional medical information and evaluations from, for example, a 
primary care physician or medical specialist. Also, a special issuance 
may be subject to operational limitations for safety reasons, or may 
be valid for a shorter time period than an unrestricted medical 
certificate. As a provision of the special issuance, FAA may authorize 
AMEs to make future medical determinations of the applicant--separate 
from the centralized special issuance process--under the AME Assisted 
Special Issuance (AASI) process.[Footnote 15] Figure 1 describes the 
medical certification process and various outcomes. 

Figure 1: Overview of FAA's Medical Certification Process: 

[Refer to PDF for image: process illustration] 

1. Applicant completes the medical history and general information 
portion of the medical application form and submits it via FAA's 
online application system. 

2. Applicant must schedule medical exam with an aviation medical 
examiner (AME) within 60 days of submitting the medical application 
form, or else the application will be voided. 

3. AME examines applicant's medical application form, administers 
medical exam, and determines whether to issue a medical certificate; 
deny the application; or, defer the action to the FAA. The AME must 
generally transmit completed medical application forms and medical 
examinations, electronically via the Aerospace Medical Certification 
System (AMCS), to the Aerospace Medical Certification Division (AMCD) 
within 14 days after completing the medical exam (or within 7 days for 
student pilot applicants). 

4. Issue a medical certificate; 
or: 

5. Deny the application: 
An AME's denial of a medical certificate is not a final FAA denial. An 
applicant may ask for reconsideration of an AME's denial by submitting 
a written request to the Federal Air Surgeon (next step). 

6. Defer the action to the Manager of the Aerospace Medical 
Certification Division (AMCD) or the appropriate Regional Flight 
Surgeon (RFS). If the AMCD or a RFS finds that the applicant is not 
qualified, the applicant is denied and advised of further 
reconsideration and appeal procedures. These may include 
reconsideration by the Federal Air Surgeon (FAS). 

7. Issue a medical certificate; 
or: 

8. RFS, AMCD, and FAS may deny medical certificate for various reasons: 
The appeals process for pilots who are denied a medical certificate 
generally includes the ability to appeal a FAA denial to an 
Administrative Law Judge at the National Transportation Safety Board 
(NTSB), appeal an Administrative Law Judge decision to the full 
National Transportation Safety Board (NTSB), appeal an NTSB decision 
to a U.S. District Court (a provision of the Pilot's Bill of Rights) 
or a U.S. Court of Appeals, which lastly, may be appealed to the U.S. 
Supreme Court. 

9. At the discretion of the FAS, a RFS, or the Manager of AMCD, a 
special issuance, valid for a specified period, may be granted to an 
applicant who does not meet the established medical standards if the 
applicant demonstrates that he or she can perform flight operations at 
the level of certification applied for, without endangering public 
safety and for the period in which the special issuance would be 
valid. Additional medical tests, examinations, or evaluation may be 
needed for a special issuance, and operational limitations may apply. 

Source: GAO analysis of FAA information. 

[End of figure] 

According to FAA, on average, from 2008 through 2012, approximately 
98.8 percent of the applications were approved and issued medical 
certificates, including approximately 8.5 percent of applications 
approved for a special issuance after additional FAA review. About 1.2 
percent of all applications were denied an FAA medical certificate 
because (1) they did not meet FAA's medical standards and did not 
provide sufficient medical information to demonstrate that their 
condition was adequately controlled and stable, or (2) because of 
questions about the applicant's fitness for certification that were 
deemed to be cause for disqualification, such as arrest(s) and/or 
conviction(s) affecting driving privileges or an intentional false 
statement on their application form that precluded them from obtaining 
a medical certificate.[Footnote 16] FAA regulations require each 
person holding certain FAA certificates, such as a medical 
certificate, to provide a written report to the FAA of each motor-
vehicle-related conviction or administrative action within 60 days of 
such action.[Footnote 17] 

Experts Generally Agreed with FAA's Medical Standards and Supported 
FAA's Move toward a Data-Driven Approach to Its Certification Process: 

FAA Uses Several Approaches to Update Its Medical Standards: 

According to FAA officials, pilot medical standards were developed to 
help manage safety risk. FAA's current medical standards have been 
codified in federal regulation since March 19, 1996. The regulations 
set out 15 medical conditions that are specifically disqualifying. 
Medical conditions identified during an evaluation that are not 
specifically listed as disqualifying but do not meet the general 
medical standard regarding safe performance of duties and exercise of 
privileges, are also disqualifying under general medical standards, 
according to FAA. (See app. II for a summary of selected FAA medical 
standards.) According to FAA officials, the standards and the medical 
certification process were developed to manage the risk of an aircraft 
accident or incident by identifying applicants with medical conditions 
that could potentially incapacitate them in the flight environment or 
during critical take-off and landing periods.[Footnote 18] 

FAA takes steps designed to ensure that its medical policies and 
procedures are consistent with current medical and aeromedical 
practice, and that these steps result in periodic updates to its 
medical policies. The Federal Air Surgeon establishes medical policies 
and medical certification procedures that are published in internal 
guidance for FAA's Office of Aerospace Medicine and for AMEs in the 
Guide for Aviation Medical Examiners (AME Guide). The agency uses 
several techniques to update policies: 

* First, the Aeromedical Standards and Policies Branch develops policy 
recommendations for the Federal Air Surgeon, which address medical 
conditions, medication use, and medical procedures. According to FAA 
officials, medical policy review is a continuous process influenced by 
several factors, which include (1) announcements of significant new 
developments in the medical literature; (2) medical appeals to the 
Federal Air Surgeon; (3) announcements and alerts by the Food and Drug 
Administration; (4) inquiries by aviation stakeholder groups and pilot 
advocacy groups; (5) aircraft accidents or events; (6) inquiries by 
the Office of Aerospace Medicine personnel and AMEs; and (7) 
communications with international aviation authorities, and medical 
advocacy groups, among other things. 

* Second, according to FAA officials, the agency refers dozens of 
individual cases annually for independent review by experts in a wide 
variety of medical specialties, such as cardiology, psychology, and 
neuropsychology. FAA officials stated that implicit to the process of 
reviewing each case is to consider changes to current policy based on 
current medical practice. FAA also periodically uses independent 
medical experts to evaluate its medical policies, particularly with 
regard to cardiovascular conditions, which were present in more than 
one-third of the applicants who received special issuances in 2012. In 
January 2013, for example, FAA hosted a cardiology roundtable to 
review FAA's policies with regard to cardiovascular conditions and to 
suggest updates to the policies, if necessary. The roundtable's 
suggested policy changes were presented to the Federal Air Surgeon, 
who approved several of them. However, FAA officials have said that 
they do not convene such roundtables frequently due to time and cost 
constraints. 

* Third, the results of CAMI's aerospace medical and human factors 
research have been used to inform changes to FAA guidance and 
policies. In particular, CAMI's aerospace medical research focuses on 
the biomedical aspects of flight, including studies on aviation safety 
associated with biomedical, pharmacological, and toxicological issues. 
For example, CAMI's research on sedating medication influenced 
guidance in this area. According to FAA officials, a review of 
accident investigation data showed that many pilots involved in 
accidents were using over the counter and prescription sedative 
medications. As a result, FAA, in coordination with the aviation 
industry, issued guidance extending the length of time a pilot should 
wait after using these medications and before operating an aircraft. A 
letter jointly signed by the FAA and all major aviation advocacy 
groups was sent to all pilots and published on the FAA website and in 
various public and private publications advising pilots to comply with 
the new guidance. 

* Fourth, CAMI's library allows research staff to collect and review 
academic journals on aviation medical issues, general medical 
research, engineering, management, and other general topics. CAMI 
researchers have also published approximately 1200 aerospace medicine 
technical reports on topics including, for example, pilot age, alcohol 
and substance abuse, fatigue, psychology, and vision.[Footnote 19] 
FAA's policy branch periodically reviews this and other medical 
literature, which FAA officials say can also result in a possible 
revision. 

In addition, FAA has recently begun analyzing aviation accident 
information to develop a predictive model based on historic data of 
medical conditions that have been identified as contributing factors 
to aircraft accidents. The officials stated that they plan to use the 
model as a data-driven guide to help inform how they determine the 
relative risk of various medical conditions. FAA officials noted that 
the agency has begun this work as part of a broader Safety Management 
Systems (SMS) initiative that seeks to further enhance safety by 
shifting to a data-driven, risk-based oversight approach.[Footnote 20] 

Experts Generally Agreed FAA's Medical Standards Are Appropriate, but 
Some Experts Suggested Modifying Some Policies: 

All aerospace medical experts we interviewed generally agreed that 
FAA's medical standards were appropriate, and most (16 of 20) said 
that the standards should be applied to commercial and private pilots. 
[Footnote 21] Some of these experts said that standards should apply 
equally to private pilots because they share airspace with commercial 
pilots or because private pilots typically do not fly with a copilot--
an important safety feature for commercial flight operations. In 
addition, although some of the experts (7 of 20) suggested no changes 
to FAA's policies, many of the experts (13 of 20) identified at least 
one medical standard for which they considered FAA's policies to be 
either too restrictive or too permissive. A restrictive policy might 
lead FAA to deny certification to an applicant who may be sufficiently 
healthy to safely fly a plane, or may result in FAA requiring a more 
thorough medical evaluation than the experts considered necessary. A 
permissive policy, on the other hand, might lead FAA to certify an 
applicant with health issues that could impair his or her ability to 
safely fly a plane, or may result in FAA not completing as thorough a 
medical evaluation as the experts considered necessary. 

Although expert opinions varied regarding which standards were too 
permissive or restrictive, neurological issues were most commonly 
discussed by some (9 of 20) of the experts.[Footnote 22] For example, 
some experts noted that the FAA medical certification requirements for 
applicants who use antidepressants, including selective serotonin 
reuptake inhibitors (SSRI), are restrictive and onerous and may 
require an applicant not to fly for an extended period of time. A 
medical representative from the Aircraft Owners and Pilots Association 
(AOPA) said that FAA's policies may require a pilot using 
antidepressants to undergo costly cognitive studies that were viewed 
as medically unnecessary for milder cases of depression. 

Alternately, some medical experts said that policies regarding 
cognitive functioning in aging pilots, traumatic head or brain 
injuries, and attention deficit disorders may be too permissive. An 
FAA official stated that the area of neurology is complex and has been 
somewhat difficult for AMCD due, in part, to variation in opinion as 
to how to assess cognitive function and when testing should be done. 
The agency hosted a neurology summit in 2010 that convened neurology 
experts to review FAA policies on neurological issues--including 
traumatic brain injury, migraine headaches, and neurocognitive testing-
-and resulted in recommendations that the Federal Air Surgeon adopted 
regarding migraine treatments, among other neurological conditions. 
Also, the Division Manager of AMCD said that they consult with 
neurologists, as needed, to review the application of certification 
policies regarding individual applicant cases. 

To a lesser extent, some (5 of 20) experts had mixed views on the 
policies for diabetes and medical conditions related to endocrine 
function. Of those, three experts thought that FAA's current policies 
on diabetes might be too restrictive, for example, because the FAA has 
not kept pace with medical advances and treatment options currently 
available to pilots. One expert noted that some commercial pilots with 
insulin treated diabetes mellitus (ITDM) may be medically fit to fly a 
plane with a special issuance if they can demonstrate that their 
condition is stable, just as private pilots are allowed to do. In 
addition, representatives from the American Diabetes Association and a 
member of the Regional Airline Association stated that FAA's policies 
for commercial pilots with ITDM have not kept current, when 
considering the advancements in medical treatment of ITDM and the 
redundancy of having a copilot and crew in commercial aircraft to 
reduce the risk associated with commercial pilots with ITDM. 
Conversely, two experts thought that FAA may be too permissive with 
regard to diabetes, citing, for example, concerns about the increase 
in diabetes among Americans, in general, and the potential for 
undiagnosed cases.[Footnote 23] FAA officials agreed that there have 
been improvements in the clinical care for diabetes and the Office of 
Aerospace Medicine has studied the safety and efficacy of new diabetes 
treatment over the past several years, including the risks associated 
with new medications and insulin formulations. However, according to 
FAA officials, independent consultants--including endocrinologists and 
diabetes experts--have told the FAA that the risk of incapacitation 
related to hypoglycemia has not changed regardless of advancements in 
treatment. 

All of the experts suggested ways FAA could ensure its medical 
standards are current, many of which were consistent with approaches 
FAA is already taking. For example, some of the experts (9 of 20) said 
FAA could review its medical standards at regular time intervals or as 
medical advances occur, and some (8 of 20) of the experts said FAA 
could review its medical standards based on evidence of the likelihood 
of each condition causing an accident. Some experts (5 of 20) 
specifically suggested FAA should convene a panel on neurology and 
mental health issues. FAA convened a panel on neurological issues in 
2010. 

Experts Suggested FAA Should Continue Efforts to Make the 
Certification Process Data-Driven: 

As previously mentioned, FAA is currently undertaking an agency-wide 
initiative--SMS--that seeks to further enhance safety by shifting to a 
data-driven, risk-based safety oversight approach. As part of this 
approach, FAA implemented the Conditions an AME Can Issue, or CACI, 
program in April 2013. The CACI program authorizes AMEs to issue 
medical certificates to applicants with relatively low risk medical 
conditions that had previously required a special issuance from the 
FAA.[Footnote 24] FAA developed the program by identifying medical 
conditions that, in most cases, did not pose a safety risk, based on 
FAA analysis of historic medical and accident data. Agency officials 
expect the program to allow more applicants to be certified at the 
time of their AME visit while freeing resources at FAA to focus on 
medically complex applicants with multiple conditions or medical 
conditions that may pose a greater risk to flight safety, such as 
applicants who have had coronary artery bypass surgery. 

Based on information provided by FAA, as of December, 31, 2011, 
approximately 19 percent of all pilots reported medical conditions 
that may now be evaluated by their AME as a result of the CACI 
program. Of those pilots, about one-third--or nearly 39,000 pilots--
reported no additional medical conditions, making it more likely that 
in the future, they may be certified at the time of their AME visit, 
rather than through the special issuance process. Other medical 
conditions have been proposed for the CACI program but have not yet 
been approved by FAA officials.[Footnote 25] Most medical experts (18 
of 20) we interviewed approved of the CACI program, and some (8 of 20) 
believed that FAA should continue to expand it to include additional 
medical conditions. Representatives of an industry association agreed 
and noted that by authorizing AMEs to make a greater number of medical 
certification decisions, AMCD officials could speed up the application 
process for more applicants. 

Some (8 of 20) aerospace medical experts we interviewed identified 
specific, relatively common medical conditions that currently require 
an FAA authorization for a special issuance that they believe should 
be considered under the CACI program. Their suggestions included, for 
example, non-insulin-treated diabetes, which was a factor in about 17 
percent of the special issuances in 2012; sleep apnea and other sleep 
disorders, which were a factor in about 11 percent of the special 
issuances in 2012;[Footnote 26] and various forms of cancer, which 
were a factor in about 10 percent of special issuances in 
2012.[Footnote 27] FAA officials have begun to allow AMEs to make 
medical determinations for applicants with certain types of cancer 
under the CACI program and have said that they will evaluate other 
medical conditions to include in the CACI program in the future. 

Although neurological conditions (including migraines, head trauma, 
stroke, and seizures) accounted for approximately 4 percent of special 
issuances in 2012, some experts (5 of 20) thought, as mentioned above, 
that FAA should convene an expert panel to re-evaluate its policies in 
this area. Half of the experts we interviewed also said that FAA could 
evaluate its medical standards based on the relative risk of 
incapacitation associated with various medical conditions, assessed 
through greater use of data. That is, with a better understanding of 
the likelihood of each medical condition to cause a suddenly 
incapacitating event in flight--based on historic data of accidents 
and incidents--FAA could modify its risk threshold for various medical 
standards and policies to manage risk.[Footnote 28] 

As previously mentioned, FAA has begun to collect and analyze data 
that will help it develop a proactive approach to managing aviation 
medical risk; however, FAA officials told us that data from historic 
accidents and incidents can be difficult to obtain and link to medical 
causes. The officials also said that they would need to change how 
they code, or classify, the medical information they collect--and re-
code medical information they already have--to more accurately 
classify medical conditions of applicants and, therefore, improve the 
reliability of their predictive model. Without more granular data 
collection on health conditions, officials said it is difficult for 
FAA to accurately determine the level of risk, associated with various 
medical conditions. In addition, officials at FAA and NTSB noted that 
data on medical causes of accidents and incidents are likely to be 
incomplete because not all accidents are investigated in the same way 
and medical causation can be difficult to prove in light of other 
contributing factors. For example, an official from NTSB explained 
that there are different levels of medical investigations performed 
after accidents, depending on factors like whether or not the pilot 
has survived, the condition of the aircraft or severity of the crash, 
and the number of people impacted. As of February 14, 2013, NTSB and 
FAA agreed to a memorandum of understanding (MOU) that will facilitate 
NTSB's data sharing and record matching for aircraft accidents and 
incidents with CAMI. 

FAA Has Identified Technical Solutions to Improve Its Medical 
Certification Systems, but Has Not Set Time Frames for Implementation: 

Although most medical certification determinations are made by one of 
the approximately 3,300 FAA-designated AMEs at the time of an 
applicant's medical exam, approximately 10 percent of applications--or 
nearly 40,000 annually--are deferred to FAA for further medical 
evaluation if the applicant does not meet FAA's medical standards or 
has a disqualifying medical condition. According to FAA officials, the 
10 percent of applicants who are deferred requires a significant 
amount of resources from FAA's medical certification division, which 
in recent years, has experienced a backlog of special issuance 
applications in need of review. As of February 2014, an FAA official 
estimated this backlog at about 17,500 applications. 

FAA has not met its internal goals for responding to individuals whose 
applications have been deferred. Specifically, FAA has set an internal 
goal of 30 working days to make a medical determination or to respond 
to an applicant with a request for further information. However, 
according to FAA data, the average time it takes FAA officials to make 
a medical determination or request further information from an 
applicant has increased over the past 6 fiscal years, taking an 
average of approximately 45 working days--or about 9 weeks--in fiscal 
year 2013, and more than 62 working days in December 2013.[Footnote 
29] If FAA makes multiple requests for further information from an 
applicant, the special issuance process can take several months or 
longer. 

Officials from AOPA stated that some applicants for private pilot 
medical certificates discontinue the application process after an 
initial denial from the FAA because the applicants decide that the 
cost of extra medical evaluations and added time is too great to 
support what the applicant views as a recreational activity.[Footnote 
30] However, an official from FAA noted that delays can also occur as 
a result of applicants who may take a long time to respond to an FAA 
request for further evaluation. According to AOPA, having information 
upfront would speed up the process by helping applicants understand 
FAA's additional medical requirements for a special issuance. FAA has 
increasingly encouraged its Regional Flight Surgeons to become more 
actively involved in making medical determinations for applicants 
seeking a special issuance. 

FAA officials at AMCD stated that there are several reasons for the 
increased processing time for applicants requiring special issuances. 
For example, AMCD has faced a technical issue deploying the Document 
Imaging Workflow System (DIWS), a web-based computer system used by 
AMCD to process, prioritize, and track all medical certification 
applications. One AMCD official noted that delays in deployment of the 
system have decreased productivity of the AMCD to as low as just 25 
percent of normal levels. In addition, officials cited multiple 
backlogs throughout the division, such as, the electrocardiogram (ECG) 
unit, which receives up to 400 ECGs each day, and the pathology-coding 
unit, which may require manual coding of medical conditions to feed 
information into DIWS. 

Part of the challenge, identified in FAA's National Airspace Capital 
Investment Plan, is that the current medical certification systems are 
based on obsolete technology from the 1990s. Accordingly, technical 
working groups at AMCD have identified more than 50 problems and 
potential technological solutions to enhance their systems, including 
the special issuance processes, of which about 20 have been identified 
as high-priority, including improvements to the online application 
system, AMCS, DIWS, and the ECG transmittal and review process. For 
example, officials stated that updating DIWS to import and read 
electronic files would reduce the need to manually scan from paper 
documents, and providing AMEs or applicants limited access to DIWS so 
they can check the status of an application could reduce the number of 
calls AMCD receives at its call center.[Footnote 31] As of February 
2014, FAA officials stated they received funding they requested in 
June 2013, to upgrade the ECG system from analog to digital--a process 
which they estimate will take about 11 months to complete. In 
addition, FAA has not established a timeline for implementing its 
broader set of technology enhancements, some of which may be less 
contingent on resource constraints. A timeline to guide the 
implementation of the highest-priority enhancements would help the 
agency take another step toward reducing the delays and bottlenecks in 
the special issuance process related to FAA's technology issues. 

In addition to the proposed enhancements, the Office of Aerospace 
Medicine collaborated with the Volpe National Transportation Systems 
Center (Volpe Center), in 2013, to define broader challenges of the 
current medical certification process and develop a strategy to 
reengineer the existing business processes, including the online 
medical-certification system and its supporting information-technology 
infrastructure. Officials from the Office of Aerospace Medicine have 
said that their effort with the Volpe Center will ultimately inform 
their plan to replace FAA's current medical information systems with 
the Aerospace Medicine Safety Information System (AMSIS), which the 
agency plans to begin developing in fiscal year 2015. FAA officials 
stated that they envision several long-term positive changes that may 
result from AMSIS--including redesigning the online application system 
and form, providing applicants with information on actions to complete 
before they meet with their AME, and a more transparent special 
issuance process with the capacity for applicants to check the status 
of their applications. However, FAA officials have also identified 
several challenges to implementing AMSIS, including working within the 
confines of legal and regulatory requirements, protecting sensitive 
information, and obtaining the estimated $50 million needed to fund 
the system. 

FAA Could Enhance its Online Application System and the Clarity of its 
Medical Application Form for Private Pilots: 

FAA Could Enhance Usability of its Online Medical Application System: 

One of FAA's main tools to communicate its medical standards directly 
to applicants, and to solicit medical information from them, is its 
online medical application system. While FAA also offers training and 
produces pamphlets, videos, and other educational material for AMEs 
and pilots, the online medical application system is used by all 
applicants to apply for a medical certificate. (See app. III for FAA's 
training programs and other communication tools for AMEs and pilots). 
The system includes information such as the online medical-application 
form and instructions used by applicants to submit medical information 
to their AME and to FAA, and a link to the AME Guide, which contains 
pertinent information and guidance regarding regulations, examination 
procedures, and protocols needed to perform the duties and 
responsibilities of an AME. 

We compared the online application system with select guidelines 
related to content, navigation, and design that are considered good 
practices by Usability.gov.[Footnote 32] Based on our evaluation and 
discussion with experts, we identified areas in which FAA might 
enhance the usability of the online application system by (1) 
providing useful information directly to applicants, and (2) using 
links to improve how applicants navigate through the application 
system. 

Providing Additional Useful Information Directly to Applicants: 
According to Usability.gov, a good practice in website design includes 
providing useful and relevant information that is easy to access and 
use. Some experts (7 of 20), including four who were also AMEs, said 
that applicants may be unsure about medical requirements and 
documentation. Representatives of two aviation medical associations 
also said a lack of clarity can lead to delays in processing the 
medical certification if applicants learn during their medical 
examination that they must obtain additional test results or 
documentation from their primary care physician. Some medical experts 
(4 of 20) said that technological improvements would be helpful. For 
example, FAA could develop a Web page on its website or within the 
online application system with more information for applicants. In 
addition, two pilot associations stated that a specific Web page or 
website for applicants with links to information on various medical 
conditions, their risks to flight safety, and additional medical 
evaluations that might be needed for applicants with those conditions 
would be helpful. The online application system currently contains a 
link to the AME Guide; however, applicants may find the 334-page AME 
Guide--written for aviation medical examiners--difficult to navigate 
and understand and therefore, may be unable to find information about 
specific documentation and additional medical evaluations they may 
need. 

FAA officials in the medical certification division said that 
providing documentation requirements to applicants could reduce 
certification delays, AME errors, and the number of phone calls to 
AMCD's medical certification call center because the applicants would 
know what additional evaluations or documents they should get from 
their primary care physician before they visit their AME for a medical 
exam. Similarly, the FAA officials noted that applicants may not 
recall information they had previously reported in prior medical 
certificate evaluations or may not disclose their complete medical 
history when they see a new AME. NTSB officials stated that the AME 
cannot see information about any previous applications and knows only 
what the pilot has reported on their current application. This means 
that the applicant has to recall all of his or her past medical 
history each time they apply for a medical certificate. Additionally, 
according to the NTSB officials, it would be useful for the pilot to 
access previously reported information and update only what has 
changed since their previous exam. As part of the more than 50 
technological solutions discussed earlier that FAA has identified to 
enhance the special issuance process, the agency has proposed 
providing access to worksheets which specify required medical 
documentation and providing access to previously reported medical data 
to applicants and AMEs. FAA officials stated that these issues, if 
addressed, would facilitate information flow between the applicant, 
the AME and FAA and allow AMCD officials to more efficiently do their 
work. 

Additionally, some experts (9 of 20) said that it would be helpful to 
applicants and treating physicians if FAA posted a list of banned 
medications. In a couple experts' view, without a public list of 
banned medications, applicants may not disclose their medical 
treatment regimen to FAA out of fear of losing or not receiving their 
certification. NTSB recommended in 2000 that DOT develop a list of 
approved medications and/or classes of medications that may be safely 
used when operating a vehicle; however, DOT--including FAA--did not 
implement the recommendation because, in DOT's view, a list of 
approved medications would be difficult to maintain and would be a 
liability for the transportation industry if the Department approved a 
medication that later caused an accident.[Footnote 33] Officials from 
AOPA told us that the association provides an unofficial list of 
approved and banned medications to its members but believes that this 
information should be made public and provided by FAA. 

However, FAA states in its AME guide that maintaining a published list 
of approved medications would not contribute to aviation safety 
because it doesn't address the underlying medical condition being 
treated. Instead, FAA's current policy prohibits AMEs from issuing 
medical certificates to applicants using medications that have not 
been on the market for at least one year after approval by the Food 
and Drug Administration (FDA), and FAA has recently updated its AME 
Guide, to include a "Do Not Issue--Do Not Fly" list of several general 
classes of medication and some specific pharmaceuticals and 
therapeutic medications.[Footnote 34] The "Do Not Issue" list names 
medications that are banned--meaning the AME should not issue a 
medical certificate without clearance from FAA--and the "Do Not Fly" 
list names medications that the pilot should not use for a specified 
period of time before or during flight, including sleep aids and some 
allergy medications. FAA officials said that the "Do Not Issue--Do Not 
Fly" list is intended to be a "living document" that they will revisit 
periodically. NTSB officials suggested that it would be helpful if 
medications that an applicant discloses on the medical application 
form could be automatically checked against the "Do Not Issue--Do Not 
Fly" list to notify their AME of the applicant's use of a medication 
on the list. 

Easier Website Navigation: Navigation is the means by which users get 
from page to page on a website to find and access information 
effectively and efficiently. According to Usability.gov, a good 
practice related to navigability is to use a clickable list of 
contents, thus minimizing scrolling. The Pilot's Bill of Rights 
Notification and Terms of Service Agreement--which contains a 
statement advising the applicant that responses may be used as 
evidence against the applicant, a liability disclaimer, a statement of 
privacy, and a Paperwork Reduction Act statement among other 
statements--requires the user to scroll through what equates to nearly 
10 pages of text (2,441 words over 417 lines of text), viewable 
through a small window that shows approximately 10 to 12 words across 
and four lines down at a time (see figure 2).[Footnote 35] 

Figure 2: Screenshot Showing Small Window through which the Reader 
Must Scroll Pages of Information: 

[Refer to PDF for image: web page screenshot] 

Source: FAA. 

[End of figure] 

FAA might enhance the visibility of this information and help 
applicants better understand what they are agreeing to, if it created 
a larger window with hyperlinks to help the reader navigate through 
various sections of the notification and agreement. Similarly, the 
question and answer page for applicants could be enhanced by including 
clickable links between the questions and answers to allow readers to 
more easily find answers of interest to them. 

Another good practice, according to Usability.gov, is to design 
websites for popular operating systems and common browsers while also 
accounting for differences. According to a notification on the online 
application system's log-in screen, applicants are advised to use only 
Internet Explorer to access the system. The system functions 
inconsistently across other browsers such as Google Chrome, Mozilla 
Firefox, and Apple Safari. For example, links to from the medical 
application form to its instructions do not work for Firefox or Google 
Chrome; instead, they lead the applicant back to the log-in page, 
causing any unsaved information to be lost. 

As described in the previous section, FAA officials at the medical 
certification division identified technological problems and potential 
solutions to enhance the online application system, but as of April 
2014, no changes have been made. For example, the officials observed 
that some applicants enter the date in the wrong format, switching the 
order of day and month (DD/MM/YYYY, as opposed to MM/DD/YYYY), which 
can lead to problems when the AME imports the application. As a 
result, FAA officials proposed using drop-down boxes--with the name or 
abbreviation of each month, followed by the day, and the year--to 
collect date information. This proposed solution is consistent with a 
good practice--anticipates typical user errors--highlighted by 
Usability.gov. Additionally, the officials noted that it is not 
uncommon for an applicant to be logged out of their session due to 
inactivity, resulting in a loss of data entered during the session. To 
address this, FAA proposed that the online application system 
incorporate an auto-save feature that would be activated prior to the 
session expiring--consistent with Usability.gov guidelines--to warn 
users that a Web session may be expiring after inactivity to prevent 
users from losing information they entered into the online application 
system. 

In addition to these enhancements, FAA collects some information from 
applicants and AMEs regarding their experience with the application 
process. For example, FAA operates a 24-hour call center to answer 
technical questions that applicants, and AMEs may have about the 
online application system throughout the application process. FAA also 
has surveyed AMEs and pilots to collect information about their 
experience with the medical certification process. 

FAA Could Enhance Clarity of Its Medical Application Form: 

The Plain Writing Act of 2010 requires federal agencies, including 
FAA, to write specified types of new or substantially revised 
publications, forms, and publicly distributed documents in a "clear, 
concise, well-organized" manner.[Footnote 36] Several years before the 
Plain Writing Act of 2010--in 2003--FAA issued Writing Standards 
[Footnote 37] to improve the clarity of its communication. The Writing 
Standards include guidance for anyone who writes or reviews FAA 
documents intended for internal or external distribution. FAA has 
continued to make efforts in recent years to improve its employees' 
understanding of plain language and how to incorporate it in written 
documents. FAA's Plain Language Program in the Office of 
Communications trains employees and supports Plainlanguage.gov, a 
website devoted to improving communication from the Federal government 
to the public.[Footnote 38] 

Although plain writing is only required for new or substantially 
changed government documents, and is therefore not required for the 
current medical application form, the goal of plain writing is to help 
readers find the information they need, understand what they find, and 
use it to meet their needs. In regard to the medical certification 
process, this would include helping applicants understand each 
question and more accurately complete the application form in the way 
that FAA intended. In addition, stakeholders from two pilot 
associations were concerned that unclear questions on the medical 
application form could lead to incomplete or inaccurate responses, 
which they said could also lead to applicants' being accused of 
misrepresenting themselves or falsifying information on the 
application form--an offense punishable by a fine up to $250,000 and 
imprisonment up to 5 years and may also result in a suspension or 
revocation or all pilot and medical certificates. 

More specifically, FAA's Writing Standards also recommend using active 
voice and active verbs to emphasize the doer of the action. Our 
analysis of FAA's medical application form and instructions showed 
that in some cases, FAA used passive voice although active voice would 
make the statements clearer. According to FAA's writing standards, 
because the active voice emphasizes the doer of an action, it is 
usually briefer, clearer, and more emphatic than the passive voice. 
For example, on the medical application form the current statement, 
"Intentional falsification may result in federal criminal 
prosecution," may be clearer to the applicant if stated, "If you 
intentionally falsify your responses, you may be prosecuted for a 
federal crime," or a similar, more direct way of notifying the 
applicant. However, FAA officials noted that any re-wording of legal 
warnings or disclaimers must be approved by legal counsel. 

We also asked the medical experts to review the online application 
form. In response, many medical experts (12 of 20) we interviewed 
stated that certain questions can be confusing or too broad. For 
example, some experts have said that terms like "frequent," 
"abnormal," or "medication" aren't clearly defined and therefore 
certain questions could generate inaccurate responses. For example, 
many experts (15 of 20) said that question 17a, on medication use, was 
unclear because, among other reasons, the reader may not know whether 
supplements or herbal medicines should be included. Some medical 
experts (7 of 20) also suggested adding items to question 18, about 
medical history, for areas such as cancer and sleep apnea. In 2009, 
NTSB recommended that FAA modify its medical application form to 
elicit specific information about risk factors or any previous 
diagnosis of obstructive sleep apnea.[Footnote 39] (See app. IV for a 
copy of the medical application form.) 

Many of the medical experts we consulted further suggested simplifying 
one question on the form; this question has also been examined by FAA 
officials. Specifically, the question on the form pertains to an 
applicant's arrests or convictions. For example, many experts (13 of 
20) suggested simplifying the question. FAA's writing guidance 
suggests shortening sentence length to present information clearly or 
using bullets or active voice. In addition, FAA officials from the 
medical certification division used a computer program to analyze the 
readability of the question and discovered that an applicant would 
need more than 20 years of education to understand it. 

According to FAA officials, the agency can make changes to the medical 
application form for various reasons, including, for example: 

* a response to findings or a recommendation made in a report by NTSB 
or by the Department of Transportation Inspector General, or: 

* a change in medical practices, for example, resulting from 
advancements in medicine. 

Since 1990, FAA revised the application form several times, to add or 
remove questions, change time frames related to the questions, or to 
clarify the questions, among other types of changes. When FAA 
announced in the Federal Register that it would replace its paper 
application form with an online application system, the agency said 
that the online application system would allow it to make and 
implement any needed or mandated changes to the application form in a 
timelier manner, resulting in a more dynamic form. However, agency 
officials noted that while they maintain a list of questions on the 
application form that pose problems for applicants, they do not make 
frequent changes, in part, because of the time and resources needed to 
complete a lengthy public comment and Office of Management and Budget 
(OMB) approval processes which, they say, can take up to two years. 
[Footnote 40] FAA officials also said that the Office of Aerospace 
Medicine must balance "plain language" with the requirements levied by 
FAA's General Counsel to make sure that the wording is legally correct 
and enforceable. While it will take time and resources to improve the 
clarity FAA's medical application form, if left unchanged, the 
accuracy and completeness of the medical information provided by 
applicants may not be improved. 

Conclusions: 

Aerospace medical experts we interviewed generally agreed that FAA's 
current medical standards are appropriate and supported FAA's recent 
effort to authorize its AMEs to certify a greater number of applicants 
by using a data-driven approach to assessing risk through the CACI 
program. Expanding the CACI program, as some experts suggested, could 
reduce the time it takes for applicants with lower risk conditions to 
become medically certified and, more importantly, allow FAA to 
prioritize the use of its constrained resources for medical 
determinations for applicants with the highest-risk medical conditions. 

FAA has identified approximately 50 potential technological 
enhancements to its computer systems that support its certification 
process, including adding new functionality to facilitate the process 
and provide applicants with more information about medical 
requirements. According to FAA officials, these enhancements would 
potentially reduce the workload at the medical certification division. 
Although FAA intends to eventually replace its current medical-
certification computer systems with a new Aerospace Medicine Safety 
Information System (AMSIS), temporary enhancements are expected to 
help FAA reduce the delays and bottlenecks currently posing challenges 
to the agency. FAA has not established a timeline for implementing its 
broader set of 50 proposed technological enhancements, some of which 
may be less expensive than others. A timeline to guide the 
implementation of the highest-priority enhancements would help the 
agency take another step toward reducing the delays and bottlenecks 
related to FAA's technology limitations. 

The online-application system and form that FAA uses to communicate 
directly to applicants contain confusing questions and instructions 
that do not meet FAA's own plain language guidance. In addition, 
broken links and other navigability issues make the website difficult 
to follow. Efforts to provide applicants with useful and relevant 
information and improve the clarity of the questions and instructions 
contained in the online application system and form could allow FAA to 
more clearly communicate medical requirements to applicants. These 
improvements could not only aid an applicant's understanding of the 
medical standards and requirements, but also may result in more 
accurate and complete information provided by applicants to better 
inform FAA's certification decisions. 

Recommendations for Executive Action: 

To improve the applicants' understanding of the medical standards and 
the information required to complete FAA's medical certification 
process, the Secretary of Transportation should direct the 
Administrator of FAA to: 

1. develop a timeline for implementing the highest-priority 
technological improvements to the internal-computer systems that 
support the medical-certification process, and: 

2. enhance the online medical-application system by clarifying 
instructions and questions on the medical application form and 
providing useful information to applicants. 

Agency Comments: 

We provided the Department of Transportation with a draft of this 
report for review and comment. DOT provided technical comments, which 
we incorporated into the report as appropriate, and DOT agreed to 
consider the recommendations. 

We are sending copies of this report to the Department of 
Transportation, the appropriate congressional committees, and other 
interested parties. In addition, the report will be available at no 
charge on the GAO website at [hyperlink, http://www.gao.gov]. 

If you or your staff members have any questions about this report, 
please contact me at (202) 512-2834 or dillinghamg@gao.gov. Contact 
points for our Offices of Congressional Relations and Public Affairs 
may be found on the last page of this report. Contact information and 
major contributors to this report are listed in appendix V. 

Signed by: 

Gerald L. Dillingham, Ph.D. 
Director, Physical Infrastructure Issues: 

[End of section] 

Appendix I: Objectives, Scope, and Methodology: 

The objectives of this report are to provide information on (1) FAA's 
medical standards and policies and certification processes, along with 
medical experts' views on them,[Footnote 41] and (2) steps that could 
be taken to promote private pilot applicants' understanding of FAA's 
medical requirements, including potential revisions to the medical 
application form. 

To meet these objectives, we reviewed pertinent statutes, regulations, 
and FAA documents regarding its pilot medical certification process, 
standards and application form. We also reviewed academic, trade and 
industry articles, government reports, and other relevant literature. 
We interviewed officials from FAA and the National Transportation 
Safety Board (NTSB), and other stakeholders in the pilot medical 
certification process, including officials representing government 
advocacy, medical and legal issues within the Aircraft Owners and 
Pilots Association (AOPA) and the Experimental Aircraft Association 
(EAA), the Aeromedical Advisor to the Air Line Pilots Association 
(ALPA), attorneys who assist pilots through the medical certification 
process, and representatives from the American Diabetes Association. 
[Footnote 42] In addition, we received written responses from the 
President and representatives from three member airlines of the 
Regional Airline Association, the Executive Director of the Aerospace 
Medical Association (AsMA), and the President and physician members of 
the Civil Aviation Medical Association (CAMA). We also visited the 
Civil Aerospace Medical Institute (CAMI) in Oklahoma City to interview 
representatives of FAA's Aerospace Medical Certification Division 
(AMCD), and we attended a training seminar for Aviation Medical 
Examiners (AME). To obtain expert opinions on FAA's medical standards, 
we collaborated with the National Academies' Institute of Medicine to 
identify aviation medical experts. We provided the Institute of 
Medicine with criteria and considerations for identifying experts, 
including (1) type and depth of experience, including recognition in 
the aerospace medicine professional community and relevance of any 
published work, (2) employment history and professional affiliations, 
including any potential conflicts of interest, and (3) other relevant 
experts' recommendations. From the list of 24 experts identified by 
the National Academies, we added 3 experts recommended to us and 
omitted 7 due to their unavailability, their concern that they may not 
have the expertise to respond to our questions, or their stated 
conflicts of interest. We ended up with a total of 20 aviation medical 
experts who represented private, public, and academic institutions. 
Fourteen of the experts are board certified by at least one of the 
American Board of Medical Specialties member boards, including 9 who 
are board certified in aerospace medicine. Eight of the 20 medical 
experts we interviewed are AMEs for the FAA, and 16 are pilots or have 
had pilot experience in the past. Two experts are from aviation 
authorities in Australia and New Zealand, and a third expert was from 
the United Kingdom. 

Each expert verified that they had no conflicts of interest in 
participating in our study. We conducted semi-structured interviews by 
telephone with the experts in August and September 2013 to solicit 
their views on FAA's medical standards and qualification policies, the 
medical application form, and FAA's communication with AMEs and pilot 
applicants. We also asked general questions about aviation medical 
policies, followed by specific questions about private pilots, where 
applicable. We provided all medical experts with relevant background 
information prior to our interview, and we provided the option to 
bypass questions if they believed they were unqualified to respond in 
a professional capacity. Prior to conducting the interviews, we 
pretested the interview questions with three aviation medical experts 
(two were AMEs and one was also a pilot). We conducted pretests to 
make sure that the questions were clear and unbiased and that they did 
not place an undue burden on respondents. We made appropriate 
revisions to the content and format of the questionnaire after the 
pretests. 

Each of the 20 interviews was administered by one analyst and notes 
were taken by another. Those interview summaries were then evaluated 
to identify similar responses among the experts and to develop our 
findings. The analysis was conducted in two steps. In the first step, 
two analysts developed a code book to guide how they will analyze the 
expert responses. In the second step, one analyst coded each 
transcript of expert responses, and then a second analyst verified 
those codes. Any coding discrepancies were resolved by both analysts 
agreeing on what the codes should be. We examined responses to 
determine if there were systematic differences in responses between 
experts who were and were not pilots and between experts who were and 
were not AMEs. Because we found no significant differences between the 
pilot and AME groups, we reported the results for the experts as a 
whole rather than by the pilot or AME subgroups. 

We used indefinite quantifiers throughout the report--"few" (2-3 
experts); "some" (4-9 experts); "half" (10); "many" (11-15 experts); 
and, "most" (16-19 experts)--to inform the reader of the approximate 
quantity of medical experts that agreed with a particular statement. 
We only reported on issues raised by at least two experts. We 
interviewed individuals with broad aerospace-medicine expertise to 
provide their expert opinion on FAA's medical standards and 
qualification policies. While the experts provided their opinions on 
some specific standards, we do not believe that these opinions alone 
provide sufficient evidence to recommend any specific changes to FAA 
medical standards and policies. Rather, the information from these 
interviews provides us with an overall expert assessment of FAA's 
medical standards, policies, and practices. The results of our 
interviews represent opinions among the experts we interviewed but 
cannot be generalized to the larger population of aviation medical 
experts. See table 2, below, for a list of medical experts we 
interviewed. 

Table 2: List of Medical Experts: 

Name: Brent Blue, M.D.; 
Organization: Emerg+A+Care Family Physician,St. John's Medical Center; 
FAA-designated AME: FAA Aviation Medical Examiner. 

Name: Tarah L. Castleberry, DO, MPH.; 
Organization: Assistant Professor Clinical Preventive Medicine 
Aerospace Medicine Residency University of Texas Medical Branch, 
Galveston, TX; 
FAA-designated AME: Senior FAA Aviation Medical Examiner. 

Name: Mary "Missy" Cummings, Ph.D.; 
Organization: Associate Professor of Aeronautics and Astronautics 
Massachusetts Institute of Technology; 
FAA-designated AME: [Empty]. 

Name: Peter Demitry, M.D.; 
Organization: President, 4D Enterprises; 
FAA-designated AME: [Empty]. 

Name: David Gradwell, M.D., Ph.D.; 
Organization: Professor, Aerospace Medicine Kings College London, UK; 
FAA-designated AME: [Empty]. 

Name: Bernard Harris, M.D., M.B.A.; 
Organization: CEO and Managing Director of Vesalius Ventures; 
FAA-designated AME: [Empty]. 

Name: Richard T. Jennings, M.D.; 
Organization: Professor, Preventive Medicine and Community Health 
University of Texas Medical Branch, Galveston, TX; 
FAA-designated AME: [Empty]. 

Name: Warren Jensen, M.D.; 
Organization: Professor, Department of Aviation Director of 
Aeromedical Research University of North Dakota Odegard School of 
Aerospace Sciences; 
FAA-designated AME: Senior FAA Aviation Medical Examiner. 

Name: Kris Lehnhardt, M.D.; 
Organization: Assistant Professor George Washington University School 
of Medicine and Health Sciences; 
FAA-designated AME: [Empty]. 

Name: Daniel Masys, M.D.; 
Organization: Affiliate Professor, Biomedical and Health Informatics 
University of Washington; 
FAA-designated AME: [Empty]. 

Name: Pooshan Navathe, MBBS, M.D.; 
Organization: Principal Medical Officer Civilian Aviation Safety 
Authority Australia; 
FAA-designated AME: [Empty]. 

Name: Robert R. Orford, M.D., M.P.H.; 
Organization: Assistant Professor of Medicine Division of Preventive, 
Occupational, and Aerospace Medicine Mayo Clinic, Arizona; 
FAA-designated AME: Senior FAA Aviation Medical Examiner. 

Name: Scott E. Parazynski, M.D.; 
Organization: Chief Medical Officer Director, Center for Polar Medical 
Operations University of Texas Medical Branch, Galveston, TX; 
FAA-designated AME: [Empty]. 

Name: Russell Rayman, M.D.; 
Organization: Former Director, Aerospace Medical Association; 
FAA-designated AME: [Empty]. 

Name: Dennis Sager, M.D.; 
Organization: Associate Clinical Professor of Health Care Sciences 
George Washington University, Private Practice; 
FAA-designated AME: Senior FAA Aviation Medical Examiner. 

Name: Warren S. Silberman, D.O., MPH; 
Organization: Contractor for Aircraft Owners and Pilots Association 
Former Program Manager, FAA Aerospace Medical Certification; 
FAA-designated AME: Senior FAA Aviation Medical Examiner. 

Name: Quay Snyder, M.D., MSPH; 
Organization: ALPA Aeromedical Advisor; 
FAA-designated AME: [Empty]. 

Name: Jan Stepanek, M.D., M.P.H.; 
Organization: Associate Professor of Medicine Mayo Clinic College of 
Medicine Director, Aerospace Medicine Program; 
FAA-designated AME: Senior FAA Aviation Medical Examiner. 

Name: Dougal Watson MB, BS, BScMed; 
Organization: Principal Medical Officer New Zealand Civil Aviation 
Authority; 
FAA-designated AME: [Empty]. 

Name: Richard Williams, M.D.; 
Organization: Chief Health and Medical Officer National Aeronautics 
and Space Administration; 
FAA-designated AME: Senior FAA Aviation Medical Examiner. 

Source: GAO, based on information provided by selected medical experts. 

[End of table] 

In addition to asking medical experts and other stakeholders about 
their view of FAA's communication of its medical certification 
requirements, we reviewed MedXPress.faa.gov (online application 
system) used by pilots to obtain a medical certificate. We reviewed 
the Pilots Bill of Rights Notification and Terms of Service Agreement, 
Form 8500-8 (medical application form) and instructions, and links 
within the online application system, evaluating that information 
against federal government website-usability guidelines and against 
FAA's plain language guidelines. We evaluated the online application 
system based on the following criteria (1) content--whether the 
website contained relevant and appropriate information users need--and 
(2) navigation--how easily users can find and access information on 
the site and move from one webpage to another, focusing on, for 
example, the clickable links within a website and limited reliance on 
scrolling. In addition, we reviewed various other website usability 
resources and criteria, including Usability.gov, to understand the key 
practices for making websites easy to use and helpful. We evaluated 
the medical application form and its instructions based on criteria 
established by FAA's Office of Communications, including its Plain 
Language Tool Kit and its Writing Standards. These criteria include 
(1) writing principles--for example, whether the document is 
appropriate for its audience, its content is well organized, and it 
uses active voice, clear pronouns, and short sentences and paragraphs--
and, (2) formatting principles--for example, whether the document 
layout and use of headers and blank space conform with best practices 
to clearly present information to the reader. 

We conducted this performance audit from January 2013 through April 
2014, in accordance with generally accepted government auditing 
standards. Those standards require that we plan and perform the audit 
to obtain sufficient, appropriate evidence to provide a reasonable 
basis for our findings and conclusions based on our audit objectives. 
We believe that the evidence obtained provides a reasonable basis for 
our findings and conclusions based on our audit objectives. 

[End of section] 

Appendix II: Summary of Selected FAA Medical Standards: 

Medical Certificate Pilot Type: Frequency of medical requirement; 
First-Class Airline Transport Pilot: Every 6 months if more than 40 
years old; Every year if less than 40 years old; 
Second-Class Commercial Pilot: Every year, regardless of age; 
Third-Class Private Pilot: Every 2 years if more than 40 years old; 
Every 5 years if less than 40 years old. 

Medical Certificate Pilot Type: Distant Vision; 
First-Class Airline Transport Pilot: 20/20 or better in each eye 
separately, with or without correction; 
Third-Class Private Pilot: 20/40 or better in each eye separately, 
with or without correction. 

Medical Certificate Pilot Type: Near Vision; 
First-Class Airline Transport Pilot: 20/40 or better in each eye 
separately (Snellen equivalent), with or without correction, as 
measured at 16 inches. 

Medical Certificate Pilot Type: Intermediate Vision; 
First-Class Airline Transport Pilot: 20/40 or better in each eye 
separately (Snellen equivalent), with or without correction at age 50 
and over, as measured at 32 inches; 
Third-Class Private Pilot: No requirement. 

Medical Certificate Pilot Type: Color Vision; 
First-Class Airline Transport Pilot: Ability to perceive those colors 
necessary for safe performance of airman duties. 

Medical Certificate Pilot Type: Hearing; 
First-Class Airline Transport Pilot: Demonstrate hearing of an average 
conversational voice in a quiet room, using both ears at 6 feet, with 
the back turned to the examiner or pass one of the audiometric tests 
below. 

Medical Certificate Pilot Type: Audiology; 
First-Class Airline Transport Pilot: Audiometric speech discrimination 
test: Score at least 70% reception in one ear. Pure tone audiometric 
test. Unaided, with thresholds no worse than: 
500 Hz; 
Better Ear: 35 Db; 
Worse Ear: 35 dB; 
1,000 Hz: 
Better Ear: 30 dB; 
Worse Ear: 50 dB; 
2,000 Hz: 
Better Ear: 30 dB; 
Worse Ear: 50 dB; 
3,000 Hz: 
Better Ear: 40 dB; 
Worse Ear: 60 dB. 

Medical Certificate Pilot Type: ENT; 
First-Class Airline Transport Pilot: No ear disease or condition 
manifested by, or that may reasonably be expected to be maintained by, 
vertigo or a disturbance of speech or equilibrium. 

Medical Certificate Pilot Type: Pulse; 
First-Class Airline Transport Pilot: Not disqualifying per se. Used to 
determine cardiac system status and responsiveness. 

Medical Certificate Pilot Type: Blood Pressure; 
First-Class Airline Transport Pilot: No specified values stated in the 
standards. The current guideline maximum value is 155/95. 

Medical Certificate Pilot Type: Electro-Cardiogram (ECG); 
First-Class Airline Transport Pilot: At age 35 and annually after age 
40; 
Second-Class Commercial Pilot: Not routinely required. 

Medical Certificate Pilot Type: Mental; 
First-Class Airline Transport Pilot: No diagnosis of psychosis, or 
bipolar disorder, or severe personality disorders. 

Medical Certificate Pilot Type: Substance Dependence And Substance 
Abuse; 
First-Class Airline Transport Pilot: A diagnosis or medical history of 
"substance dependence" is disqualifying unless there is established 
clinical evidence, satisfactory to the Federal Air Surgeon, of 
recovery, including sustained total abstinence from the substance(s) 
for not less than the preceding 2 years. A history of "substance 
abuse" within the preceding 2 years is disqualifying. "Substance" 
includes alcohol and other drugs (i.e., PCP, sedatives and hynoptics, 
anxiolytics, marijuana, cocaine, opioids, amphetamines, hallucinogens, 
and other psychoactive drugs or chemicals). 

Medical Certificate Pilot Type: Disqualifying Conditions; 
First-Class Airline Transport Pilot: Unless otherwise directed by the 
FAA, the Examiner must deny or defer if the applicant has a history of 
(1) diabetes mellitus requiring hypoglycemic medication; (2) Angina 
pectoris; (3) Coronary heart disease that has been treated or, if 
untreated, that has been symptomatic or clinically significant; 
(4) Myocardial infarction; (5) Cardiac valve replacement; (6) 
Permanent cardiac pacemaker; (7) Heart replacement; (8) Psychosis; 
(9) Bipolar disorder; (10) Personality disorder that is severe enough 
to have repeatedly manifested itself by overt acts; (11) Substance 
dependence; (12) Substance abuse; (13) Epilepsy; (14) Disturbance of 
consciousness and without satisfactory explanation of cause, and (15) 
Transient loss of control of nervous system function(s) without 
satisfactory explanation of cause. 

Source: 2014 Guide For Aviation Medical Examiners and 14 C.F.R. § 
61.23(d). 

[End of table] 

[End of section] 

Appendix III: Selected FAA Training Programs for AMEs and Pilots in 
Aerospace Medicine and Communication Tools: 

AME Training Program/Communication tool: Clinical Aerospace Physiology 
Review for Aviation Medical Examiners (CAPAME) course; 
Medical Certification Standards and Procedures Training (MCSPT); 
Description: Prospective AMEs must complete these online courses as a 
prerequisite to becoming an AME. 

AME Training Program/Communication tool: Basic AME Seminar; 
Description: Prospective AMEs generally must attend this one-week 
seminar to be designated as an AME. 

AME Training Program/Communication tool: AME Refresher Seminars; or; 
Multimedia Aviation Medical Examiner Refresher Course (MAMERC); 
Description: Practicing AMEs must complete refresher training every 
three years to maintain their designation as an AME. AMEs generally 
fulfill this requirement by either; attending an AME Refresher 
Seminar; or; 
completing the online MAMERC course in lieu of attending an AME theme 
seminar. This course can be used as a substitute for a theme seminar 
on alternate 3-year cycles, which extends the time between theme 
seminar attendance to six years. 

AME Training Program/Communication tool: AME Proficiency Requirement; 
Description: In addition to the AME training and continued 
professional refresher courses, AMEs generally maintain a proficiency 
requirement of at least 10 exams per year. 

AME Training Program/Communication tool: Guide for Aviation Medical 
Examiners; 
Description: According to the Federal Air Surgeon, FAA policies go 
into effect when they are updated in the Guide for Aviation Medical 
Examiners, available online. 

AME Training Program/Communication tool: Federal Air Surgeon's Medical 
Bulletin; 
Description: Published quarterly for aviation medical examiners and 
others interested in aviation safety and aviation medicine. The 
Bulletin is prepared by the FAA's Civil Aerospace Medical Institute, 
with policy guidance and support from the Office of Aerospace Medicine. 

AME Training Program/Communication tool: Aerospace Medical 
Certification Subsystem (AMCS); 
Description: E-mail notifications are sent to AMEs and their staff 
through AMCS. AMCS support is available by phone, (405) 954-3238, or e-
mail, 9-amc-aam-certification@faa.gov. 

Pilot Training Program/Communication tool: FAA TV and Social Media; 
[Empty]; 
Description: FAA TV, http://www.faa.gov/tv, is a central repository 
for FAA videos related to pilot medical requirements, among other 
topics. For example, FAA has produced two MedXPress videos: 
http://www.faa.gov/tv/?mediaId=554 or 
http://www.faa.gov/tv/?mediaId=634; FAA also posts videos on its 
YouTube page http://www.youtube.com/user/FAAnews/videos; FAA also uses 
Facebook and Twitter to communicate directly with pilots and others 
who choose to follow FAA through social media. 

Pilot Training Program/Communication tool: FAA Safety Briefings; 
Description: Bimonthly publications promote aviation safety by 
discussing current technical, regulatory, and procedural aspects 
affecting the safe operation and maintenance of aircraft. 

Pilot Training Program/Communication tool: FAA's Medical Certification 
web page; 
Description: FAA's medical certification webpage contains information 
for AMEs and pilots, including information about MedXPress, Health and 
Fitness, and FAA's Industry Drug and Alcohol Testing Program. 
http://www.faa.gov/licenses_certificates/medical_certification/. 

Pilot Training Program/Communication tool: FAA Pilot Safety Brochures; 
Description: FAA pilot safety brochures provide essential information 
to pilots regarding potential physiological challenges of the aviation 
environment so pilots may manage the challenges to ensure flight 
safety. Brochure topics include: Alcohol and Flying, Medications, 
Spatial Disorientation, Hearing and Noise, Hypoxia, Pilot Vision, Seat 
Belts and Shoulder Harnesses, Sleep Apnea, Smoke, Sunglasses for 
Pilots, Deep Vein Thrombosis and Travel, and Carbon Monoxide, among 
other topics. 

Pilot Training Program/Communication tool: MedXPress; 
Description: MedXPress support is available for pilots by phone, (877) 
287-6731, or e-mail, 9-natl-avs-it-servicedesk@faa.gov, 24 hours each 
day. 

Source: FAA. 

[End of table] 

[End of section] 

Appendix IV: FAA Form 8500-8 (Medical Application Form): 

[Refer to PDF for image: Illustration of Form 8500-8, 3 pages] 

Source: FAA (medxpress.faa.gov, accessed Nov. 20, 2013. 

[End of figure] 

[End of section] 

Appendix V: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Gerald L. Dillingham, Ph.D., (202) 512-2834, or dillinghamg@gao.gov: 

Staff Acknowledgments: 

In addition to the contact named above, the following individuals also 
made important contributions to this report: Susan Zimmerman, 
Assistant Director; Colin Fallon; Geoffrey Hamilton; John Healey; 
Linda Kohn; Jill Lacey; Maren McAvoy; and Sara Ann Moessbauer. 

[End of section] 

Footnotes: 

[1] Persons not required to hold a medical certificate include, among 
others, sport pilots, with glider and balloon privileges (14 C.F.R. § 
61.23(b)). 

[2] Specific medical standards and certification procedures for 
issuing medical certificates and for remaining eligible for a medical 
certificate are set out in federal regulations at 14 C.F.R. Part 67. 

[3] Pub. L. No. 112-153, 126 Stat. 1159 (2012). 

[4] Federal regulations establish three classes of medical 
certification that correspond to the duties that pilots perform. First-
and second-class pilots fly for commercial purposes, whereas third-
class pilots fly for noncommercial (private) purposes. The pilot 
medical certification process is similar for all classes of pilots. 
The General Aviation Pilot Protection Act of 2013 (H.R. 3708, 113TH 
Cong. (2013)) was introduced in December 2013 and, if enacted into 
law, would eliminate the medical certification requirement, under a 
specific set of conditions, for private (third-class) pilots flying 
recreationally. We did not review the proposed legislation and its 
potential implications as part of this study. 

[5] We selected these experts based on their relevant experience in 
aviation medicine. The experts represented private, public, and 
academic institutions. Fourteen of the experts are board certified by 
at least one of the American Board of Medical Specialties member 
boards, including nine who are board certified in aerospace medicine. 
Eight of the 20 medical experts we interviewed are Aviation Medical 
Examiners (AMEs) for the FAA, and 16 are pilots or have had pilot 
experience in the past. Two experts are from aviation authorities in 
Australia and New Zealand, and a third expert was from the United 
Kingdom. We asked each interviewee to verify that they had no 
conflicts of interest in participating in our study. 

[6] We also contacted the American College of Cardiology and the 
American Academy of Neurology to solicit their views, but they did not 
reply for an interview. 

[7] Throughout the remainder of the report, we use the term 
"applicant" to refer to new applicants and to pilots who are applying 
to periodically renew their medical certificate. 

[8] Among other statutory authorities, the Administrator of the FAA is 
required to promote safe flight of civil aircraft (49 U.S.C. § 44701) 
is authorized to issue airman certificates (49 U.S.C. § 44702) and is 
required to issue such certificates after investigation that the 
individual is qualified for, and physically able to perform the duties 
of the position authorized by the certificate (49 U.S.C. § 44703). 

[9] The National Transportation Safety Board is an independent federal 
agency charged by Congress with investigating every civil aviation 
accident in the United States and significant accidents in other modes 
of transportation. The NTSB determines the probable cause of the 
accidents and issues safety recommendations aimed at preventing future 
accidents. 

[10] Under 49 C.F.R. § 830.2, an aircraft accident means an occurrence 
associated with the operation of an aircraft that takes place between 
the time any person boards the aircraft with the intention of flight 
and all such persons have disembarked, and in which any person suffers 
death or serious injury, or in which the aircraft receives substantial 
damage. NTSB officials told us that the actual portion of accidents 
with medical causes or contributing factors may be higher because they 
do not investigate all accidents in the same way, making it difficult 
to identify medical causes in some cases. According to NTSB officials, 
methods of accident investigation may vary, depending on whether or 
not the accident was fatal, the condition of the aircraft and pilot, 
and other factors. Additionally, according to FAA officials, 30 to 50 
percent of fatal accidents are attributed to faulty aeronautical 
decision making. FAA officials also said that human behavior is 
recognized as a key component of aeronautical decision making, but the 
specifics of medical contributing factors--for example, the role of 
fatigue secondary to obstructive sleep apnea--are not well mapped. 

[11] We use the term incapacitation to refer to sudden or subtle forms 
of incapacitation. Any medical certification process would be unlikely 
to prevent all accidents with medical causes due to the unpredictable 
nature of some medically incapacitating events, such as a heart 
attack, and the relative infrequency of the medical evaluations for 
some pilots. 

[12] Pursuant to 14 C.F.R. § 61.53(a), Prohibition on operations 
during medical deficiency prohibits a person who holds a medical 
certificate from acting as pilot in command or in any other capacity 
as a required pilot flight crew member while that person: (1) "knows 
or has reason to know of any medical condition that would make the 
person unable to meet the requirements for the medical certificate 
necessary for the pilot operation"; or, (2) "Is taking medication or 
receiving other treatment for a medical condition that results in the 
person being unable to meet the requirements for the medical 
certificate necessary for the pilot operation." 

[13] Throughout the remainder of the report, we use the term 
"applicant" to refer to new applicants and to pilots who are applying 
to periodically renew their medical certificate. 

[14] FAA annually issues an Individual AME Performance Summary Report 
to each AME, which summarizes AME training and performance to help 
ensure that the AME completes required training and submits medical 
exam results to FAA in a timely manner. FAA has also developed a 
quality assurance review program to help it determine that AMEs have 
properly issued medical certificates. See GAO, Aviation Safety: FAA 
Has Taken Steps to Determine That It Has Made Correct Medical 
Certification Decisions, [hyperlink, 
http://www.gao.gov/products/GAO-08-997] (Washington, D.C.: Sept. 17, 
2008). 

[15] Alternatively, if FAA determines that an applicant's medical 
condition is static and non-progressive and has found the applicant 
capable of performing pilot duties without endangering public safety, 
the FAA may grant a Statement of Demonstrated Ability (SODA) to the 
applicant, which does not expire and authorizes AMEs to make future 
medical determinations of the applicant, without requiring the 
applicant to go through the special issuance review process. 

[16] Applicants who are denied medical certification by an AME or the 
FAA may appeal the decision (14 C.F.R. § 67.409, 49 U.S.C. 44703(d)); 
however, according to FAA officials most applicants who are denied 
medical certification do not pursue an appeal or do not provide FAA 
with additional requested information necessary for a special 
issuance. A denial is considered a "final" action by the FAA and is 
subject to review by the NTSB. The Manager of AMCD and Regional Flight 
Surgeons may also issue a final denial to an applicant who fails to 
provide additional requested information within the time frame 
specified by FAA. Based on information provided by FAA, from 2008 
through 2012, on average, approximately 4,930 applicants were denied 
each year, and about 12 percent of those denials were deemed final by 
FAA. 

[17] 14 C.F.R. § 61.15(e). 

[18] Because medical incapacitation risk is a factor of the likelihood 
an incapacitating medical event and the consequence of the event, FAA 
also may manage medical incapacitation risk by building redundancies 
in the flight environment, for example, as FAA currently manages 
safety risk, by requiring co-pilots for commercial flight. According 
to FAA officials, in addition to 'sudden' incapacitation, several 
other potential medical causes for aircraft accidents are considered 
in the medical evaluation process. These include: factors that could 
alter judgment, conditions that can alter special senses (such as 
visual acuity and color vision), factors that could alter the ability 
to communicate, conditions that may cause difficulty with coordination 
or may alter the state of alertness, and medication side effects. 

[19] [hyperlink, 
http://www.faa.gov/data_research/research/med_humanfacs/oamtechreports/]
 

[20] See, for example, GAO, Aviation Safety: Additional FAA Efforts 
Could Enhance Safety Risk Management, [hyperlink, 
http://www.gao.gov/products/GAO-12-898] (Washington, D.C.: Sept. 12, 
2012). 

[21] We interviewed 20 aviation medical experts and we use the 
indefinite quantifiers ("few" = 2-3 experts; "some" = 4-9 experts; 
"half" = 10 experts; "many" = 11-15 experts; "most" = 16-19 experts) 
to inform the reader of the approximate quantity of medical experts 
who agreed with the particular statement or idea (See app. I for an 
explanation of how these indefinite quantifiers are used, and a list 
of medical experts interviewed.) 

[22] We interviewed 20 individuals with broad aerospace medicine 
expertise to provide their expert opinion on FAA's medical standards 
and qualification policies. Our criteria for identifying and selecting 
experts included (1) type and depth of experience, including 
recognition in the aerospace medicine professional community and 
relevance of any published work; (2) employment history and 
professional affiliations, including any potential conflicts of 
interest; and (3) other relevant experts' recommendations. Our group 
of experts includes AMEs and pilots, as well as experts from aviation 
authorities in the United Kingdom, Australia, and New Zealand. Fifteen 
of the experts are board certified by at least one of the American 
Board of Medical Specialties' member boards, including nine who are 
board certified in aerospace medicine. We provided all medical experts 
with relevant background information prior to our interview, and we 
provided the option to bypass questions if experts believed they were 
unqualified to respond in a professional capacity. While the experts 
provided their opinions on some specific standards, we do not believe 
that these opinions alone provide sufficient evidence to recommend any 
specific changes to FAA medical standards and policies. Rather, the 
information from these interviews provides us with an overall expert 
assessment of FAA's medical standards, policies, and practices. 

[23] A few experts (3 of 20) also identified standards related to 
cardiovascular and drug or alcohol use as too permissive or 
restrictive. 

[24] Medical conditions that FAA deems low risk and has approved for 
an AME to issue under the CACI program include: arthritis, asthma, 
colitis/irritable bowel syndrome (IBS)/Crohn's, glaucoma, hepatitis c, 
hypertension, hypothyroidism, migraine and chronic headache, pre-
diabetes (glucose elevation/intolerance), prostate cancer, renal 
cancer, and testicular cancer, among others. 

[25] Medical conditions that were proposed but not yet approved for 
CACI, include, for example: carotid stenosis, bladder cancer, 
leukemia, and lymphoma. 

[26] As of April, 2014, FAA officials told us that they were working 
to revise the agency's sleep apnea policy and consider how it may be 
implemented, to ensure that as many applicants as possible are issued 
a medical certificate at the time of their FAA examination. FAA 
currently instructs its AMEs to screen for sleep apnea by asking 
applicants about signs or symptoms and looking for major risk factors 
of sleep apnea and related conditions as part of the medical exam. 
First-time applicants known to have sleep apnea must currently go 
through the FAA special issuance process, which requires them to 
provide results from a polysomnogram sleep study, among other 
requirements. 

[27] The percentages in this paragraph describe the portion of the 
approximately 10.2% of applicants who were granted a special issuance 
by FAA in 2012. If considering the portion of all applicants, about 
1.8 percent of all applicants had received a special issuance for non-
insulin treated diabetes; about 1.1 percent of all applicants had 
received a special issuance for sleep apnea and other sleep disorders; 
and, about 1.0 percent of all applicants had received a special 
issuance for various forms of cancer. 

[28] An example of a risk threshold that has been applied to the 
medical fitness of pilots, in the United Kingdom and elsewhere, is the 
"one percent rule," which would result in a pilot applicant being 
denied a medical certificate if their risk of medical incapacitation 
due to a particular medical condition (e.g., heart attack, stroke, 
seizure, sudden unconsciousness, etc.) was determined as being greater 
than one percent during the year. That is, if there were 100 pilots 
with an identical medical condition, one of them would be predicted to 
become incapacitated at some point during the next 12 months (and 99 
would not). 

[29] This estimate may not account for the full processing time it 
takes an applicant to complete the process, because FAA only measures 
the time that FAA's AMCD manually codes and enters applicants' 
information into its Document Imaging Workflow System (DIWS) to when 
it either makes a determination to issue or deny a medical 
certificate, or requests further information from the applicant. 

[30] FAA estimated the cost of a medical exam at $88 (in 2006 
dollars). We adjusted this value, using the consumer price index 
(CPI), which would be $102.11 (in 2014 dollars). FAA also estimated 
the hourly value of a third-class pilot's time, based on an hourly 
wage estimate, at $39.13/hour and estimated travel time for the exam 
at one-and-a-half hours; a half-hour to complete the medical 
application form; and, a one-hour exam. Using these estimates and 
adjusting to 2014 dollars, the total cost to a third-class pilot would 
be about $240 for time and exam expenses. For FAA's initial estimates, 
see: Department of Transportation, Regulatory Evaluation, Regulatory 
Flexibility Determination, International Trade Impact Assessment, and 
Unfunded Mandates Assessment (December 2007). 

[31] AMCD officials estimated that the AMCD receives about 10,000 
pieces of mail each month, much of which must be scanned and linked to 
applicant files. FAA currently employs approximately 20 FTEs to scan 
applications and supporting paperwork into DIWS, and about 8 FTE call 
center operators and one supervisor to handle about 10,000 calls per 
month. 

[32] Usability.gov, maintained by the Digital Communications Division 
of the U.S. Department of Health and Human Services, is a resource for 
federal web designers to make websites more usable, useful, and 
accessible. 

[33] NTSB closed recommendation (I-00-2) in 2010, citing unacceptable 
action by DOT, after DOT said that it had no plans to implement it. 
However, NTSB credited FAA for implementing related recommendations on 
providing information to pilots on the hazards of using specific 
medications when flying (A-00-5) and educating pilots on how they can 
access that information (A-00-6). 

[34] [hyperlink, 
http://www.faa.gov/about/office_org/headquarters_offices/avs/offices/aam
ame/guide/pharm/dni_dnf/]. 

[35] According to guidance provided by Usability.gov, short sentences 
and paragraphs are particularly important to optimize reading 
comprehension in the online environment. 

[36] Pub. L. No. 111-274, 124 Stat. 2861. 

[37] FAA's Writing Standards include: (1) writing principles--whether 
the document is appropriate for its audience, its content is well 
organized, and it uses active voice, clear pronouns, and short 
sentences and paragraphs; and, (2) formatting principles--whether the 
document layout and use of headers and font styles, conform with best 
practices to clearly present information to the reader. For more 
information, see FAA Order 1000.36 FAA Writing Standards (Mar. 3, 
2003). 

[38] On its Plain Language website, [hyperlink, 
http://www.faa.gov/about/initiatives/plain_language/], FAA provides 
links to best practices, standards, and guides. For example, the site 
contains a link to a basic plain language course, documents containing 
best practices for writing letters and writing for the Web, FAA, and 
federal government standards and guidelines, and general information 
on government plain language initiatives. 

[39] According to NTSB, obstructive sleep apnea is associated with 
excessive daytime fatigue and leads to an increased risk of accidents 
and cognitive impairment. NTSB recommendations, A-09-61 and A-09-62, 
direct FAA to do more to identify pilots and applicants likely to have 
sleep apnea. NTSB also suggested that FAA use data it already 
collects, such as an applicant's height and weight, to screen for risk 
factors associated with obstructive sleep apnea, such as a high body 
mass index (BMI) value. In response to NTSB's recommendation, FAA 
agreed with NTSB that obstructive sleep apnea among pilots is a 
significant safety hazard--if unrecognized and untreated--and proposed 
addressing the issue by promoting awareness of sleep apnea in AMEs 
through the regular AME seminar education process, but the agency did 
not modify its medical application form. 

[40] Before requiring or requesting information from the public, the 
Paperwork Reduction Act, as amended (44 U.S.C. Chapter 35) requires 
Federal agencies to, among other things, (1) seek public comment on 
proposed collections and (2) submit proposed collections for review 
and approval by the Office of Management and Budget (OMB). OMB's 
Office of Information and Regulatory Affairs (OIRA) reviews agency 
information collection requests for approval or disapproval. According 
to FAA officials and guidance from the OMB, each time the medical 
application form is updated, the FAA publishes a 60-day notice in the 
Federal Register to solicit public comments on the proposed changes, 
followed by a 30-day notice in the Federal Register after the FAA has 
considered the public comments and has submitted the changes for OMB's 
concurrent review and approval. 

[41] Private pilots hold third-class medical certifications. Airline 
transport pilots who serve as pilots in command of scheduled air 
carrier operations must hold first-class medical certificates. Pilots 
who fly for compensation or hire or serve as flight engineers or 
flight navigators generally hold second-class medical certificates. 

[42] We also contacted the American College of Cardiology and the 
American Academy of Neurology to solicit their views but they did not 
reply for an interview. 

[End of section] 

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