The Safety Investigation Authority of Finland has made significant safety findings in order to improve international aviation safety

Published 21.6.2017

The Safety Investigation Authority of Finland (SIAF) has made significant safety findings in order to improve aviation safety in both commercial and general aviation. The findings were made during the investigation of a general aviation accident where the pilot had suffered three heart attacks over five years and had sleep apnoea. The pilot had his fourth heart attack in mid-flight on 24 September 2016 and died as a result. There are clear shortcomings in the assessment system for the medical eligibility of pilots.

The UN’s International Civil Aviation Organization (ICAO) and the EU’s European Aviation Safety Agency (EASA) have taken SIAF’s safety recommendations for improving global aviation safety seriously and in a cooperative manner.

The findings are based on SIAF’s extensive rights to information on the pilot’s state of health, made possible by the provisions of the Finnish Safety Investigation Act. The comprehensive rights to information allow for determining all the necessary health factors that may have affected the accident. This is not necessarily the case elsewhere. For example, German safety investigators did not receive all information about the health history of co-pilot, who intentionally crashed a Germanwings passenger plane into the mountain in 2015. 150 people died in the accident.

SIAF’s investigation of the general aviation accident indicated that there are international opportunities for improvement in verifying the medical eligibility of pilots. It should be noted that, when assessing airworthiness following a heart attack, decision-making in the field of aviation medicine follows similar methods for general aviation, commercial aviation and air traffic controllers. A significant share of the sudden incapacitations of pilots is related to cardiovascular diseases.

An overall risk assessment of the pilot’s health was insufficient and healthcare was fragmented

SIAF’s safety investigation showed that the healthcare of the pilot, who was suffering from coronary insufficiency in several arteries and sleep apnoea, was fragmented and an overall risk assessment of their state of health was missing. The healthcare professionals treating the pilot and the authority supervising the operations did not have a common overall picture of the pilot’s health.

This was due to the fact that in Finland, like many other countries, healthcare professionals (with the exception of aviation physicians) have no duty to provide the Aviation Authority with information about a change in the pilot’s state of health that could jeopardise flight safety. The investigation indicated that information was not properly transferred between the parties assessing medical eligibility. In Norway, for example, all doctors have a duty to inform the aviation authorities in these cases.

Furthermore, the pilot did not notify the aviation authority or aviation physician of his third heart attack. Apparently, the 65-year old male thought that he still had permission and the prerequisites for flying a small aircraft.

Training in overall pilot health risk assessment

Based on its accident investigation and safety findings, SIAF recommends that the International Civil Aviation Organization (ICAO) include in its Manual of Civil Aviation Medicine a risk management model that can be used in the decision-making when assessing the risk for pilots with recurrent heart infarctions. The ICAO’s Manual of Civil Aviation Medicine provides guidance for the risk assessment of cardiological disease and it is the world’s leading point of reference when creating decision-making models.

To the European Aviation Safety Agency (EASA), SIAF recommends that EASA improve the competencies of aviation physicians in the field of aviation medicine decision-making by means of training and by improving, for example, the preparedness of aviation physicians for setting limitations related to the licensing processes of pilots. The aim is to prevent situations where the pilot becomes incapacitated during the flight.

Some aviation physicians perform aviation medicine eligibility checks on pilots fairly rarely. In particular, their experience in risk management within aviation medicine decision-making may not be at the desired level. More training should be provided to aviation physicians in the field of risk assessment.

On a national level, SIAF recommends that the Finnish Ministry of Transport extend the duty to inform the supervisory authority of a decline in the pilot’s state of health to all healthcare professionals, not only aviation physicians.

Furthermore, SIAF recommends to the Finnish Transport Safety Agency (Trafi) on a national level that civil and amateur aviators should receive more information on the rights related to the pilot’s licence and the significance of the duty to inform on medical matters.

Further information:

Veli-Pekka Nurmi, Executive Director, tel. + 358 295 150 701, veli-pekka.nurmi@om.fi
Ismo Aaltonen, Chief Safety Investigator, tel. +358 295 150 703, ismo.aaltonen@om.fi
Sakari Lauriala, Head of Communications, tel. +358 295 150 714, sakari.lauriala@om.fi

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