Mental Illness in the Cockpit

by Mark Levy MD
Medical Director fpamed

The New York Times lead article on Sunday April 19, 2015 was headlined “Germanwings Crash Exposes History of Denial of Risk of Pilot Suicide” Germanwings Crash Expose…t Suicide – NYTimes

What is most shocking among the revelations contained in this article is that there have been rare but consistent numbers of fatal commercial airline crashes that have either been proven to be caused by a suicidal pilot (such as the recent Germanwings crash) or are strongly suspected of having resulted from mental illness in the cockpit.

As a treating physician and psychiatrist in the State of California (as in most other United States), I have an “affirmative duty” (i.e., a legal obligation) to report to the State Department of Motor Vehicles when a patient of mine is diagnosed with a seizure. This is an example of where a public policy, protecting the innocent public from the the danger of a known impaired driver , overrides the privacy rights of any patient with a seizure disorder. Similar physician affirmative duties exist in law to report to appropriate authorities evidence of child or elder abuse or domestic violence. As a result of the California Supreme Court Tarasoff rulings (with similar rulings now in all 49 other United States), I and other mental health professionals actual have a “duty to protect” the possible third party victim of a violent act committed by a patient of mine when I have reason to suspect from a patient’s statements and behavior that such an injurious act may occur. This duty is usually discharged by the physician alerting civil authorities such as the local police department to the potential threat.

How peculiar it is, then, that a pilot who is regularly subjected to mandatory, physical examinations in order to continue flying and who would be grounded automatically if he was found intoxicated in the airport or suffering from chest pain, retains the full authority to decide for himself whether or not he is mentally fit to fly a commercial airliner. For example, a pilot who goes on bereavement leave following the death of a love one decides him or herself whether he is ready to return to active flight duty in the cockpit. Therefore, a pilot who suffers a sudden tragic death, or an emotionally disruptive divorce or an overwhelming financial disaster is under no regulatory obligation to undergo a psychological fitness for duty evaluation before returning to flying. Similarly, pilots who find themselves suffering from the typical symptoms of depression, e.g., sadness, anxiety, insomnia or impaired ability to concentrate, more often than not seek medical and psychiatric treatment privately (i.e., secretly) and do not reveal this information to the employer. Nor is the pilot’s physician obligated under any federal regulations or statutes to report their patient’s symptoms to the pilot’s employer or to the FAA. Does it really make sense for pilots, no matter how skilled and well trained they may be aeronautically, to be the final arbiters of their own mental status when experiencing periods of potentially disruptive and distracting emotional distress?

The culture in the cockpit has also changed over the past generation. Through the mid 1970’s, most commercial airline pilots were former military pilots. Not only had they been rigorously trained to fly and logged many hours in the air frequently including flying combat missions, they were also subjected to the rigors and discipline of being active duty military pilots and often career officers. Since military conscription ended following the Vietnam War, an ever increasing number of commercial pilots are trained not by the military but by flight schools. Although they may be equivalently educated in the technology of flying, they lack the years of flight performance under stress, even in combat missions, that characterized the backgrounds of their former military cockpit brethren. At they very least, these younger products of civil flight school training have not been vetted through the rigors of flying under close military supervision and discipline, combined with accountability to a tight military chain of command. Thus, the cockpits of commercial airlines are increasingly under the control of psychologically less tested and less vetted pilots than they were a generation ago.

It is an unfortunate fact of life that mental illness can find its way into the cockpit just as easily as it can into a firm of trial attorneys or into the operating room. Nevertheless, commercial pilots are responsible for safely transporting thousands of individual passengers and crew every week. Although, fortunately, air crash disasters are statistically rare and those caused by suicidal pilots are only an infinitesimal subset of all air disasters, the tragedy of commercial pilot suicide when it does occur such as under the control of the Germanwings co-pilot several weeks ago, can instantly cause the loss of hundreds of innocent lives and devastate those of thousands of family members. It is now increasingly evident that these pilot suicide disasters have recurred periodically throughout commercial flight history. With regular periodic psychological screening of cockpit crew, however, most such tragedies could be averted.

The solution to these rare but when they occur catastrophic tragedies requires a global plan and broad cooperation among pilots’ unions and associations, the airline industry and government regulating agencies. Pilot unions’ whose rightful concern involves protecting pilots’ jobs and personal privacy, need to be reassured by industry executives that increased transparency by pilots of their emotional status and fitness to fly will not be punished with employment, income and job security losses. Pilots need to have easy, prompt and confidential access to high quality mental health professionals who are also informed about the unique stresses affecting commercial airline pilots and their usual work conditions. These professionals need the freedom to confidentially report to the airline and the government agency when a pilot’s mental status is a cause of concern. A pilot who is going through an potentially traumatic emotional experience such as the death of a loved one, or divorce or a significant financial setback, should be able to take time off without loss of face or job or income. In fact, pilots who already utilize such mental health services to help themselves modulate their emotional stress should be commended and even celebrated for responsibly doing so. There is no reason why a pilot’s efforts to treat his emotional symptoms should be shrouded in secrecy and shame anymore than efforts to get their hypertension or elevated cholesterol levels treated. Unions need to recognize that suicide in the cockpit is usually preventable through the use of regular and thorough psychological screening procedures and psychiatric fitness for duty evaluations. The cost of not doing so is not just the loss of innocent passenger lives but also the lives of other crew members including cockpit crew such as the Captain of the Germanwings airliner who was locked out of the cockpit while his co-pilot was intentionally crashing their airplane into the French Alps.

Finally government regulatory agencies need to work cooperatively both with the industry and the pilots’ union to develop effective policies and procedures for routine screening of pilot mental status and the implementation of standardized pilot psychiatric fitness for duty evaluation protocols prior to allowing a pilot to return to flying following a period of severe emotional distress. Unexpected, sometimes traumatic life events can happen to any one of us and often do. Pilots deserve the same help getting back on their feet again and functioning productively to which the rest of us are entitled.

The methodology for fitness for duty screening is already well developed. There are currently thousands of mental health professionals (MD psychiatrists and PhD psychologists) who are competent in applying psychiatric risk assessment protocols to the evaluation of cockpit crews. On the rare occasions when mental illness has slipped into the cockpit, its consequences have contributed to catastrophic and devastating aircraft disasters. Pilot suicide must no longer remain the denied hidden secret of the airline industry. In that sense, all of the publicity and revelations about the Germanwings disaster may be a tipping point. The public is now for the first time demanding more accountability by airlines and assurances by government regulators that the cockpit and commercial flying is safe not only from terrorists but also from mentally unstable pilots.