The following article from the newspaper of the American Psychiatric Association is a follow up on previous blog posts on this fpamed.com site concerning the GermanWings crash, pilot depression and cockpit screening for potentially dangerous signs of mental illness.

From the American Psychiatric Association’s PsychiatricNews:

by Aaron Levin,
07 May 2015

No evaluation process is foolproof but U.S. procedures have helped minimize dangers of pilot failure.

The murder-suicide crash of a Germanwings passenger jet in the French Alps on March 24, coupled with revelations about the copilot’s erratic training history and likely depression, have led to questions about how pilots are screened for medical and psychiatric fitness.

In fact, the crash represents a nearly unprecedented failure of the multilayered systems designed to prevent such a catastrophe, said William Sledge, M.D., a professor of psychiatry at Yale University. Sledge, who took his first flying lessons at age 16 from a crop-dusting pilot in rural Alabama, served in the U.S. Air Force and has trained the medical specialists who screen pilots.

Fragmentary information about copilot Andreas Lubitz indicates that he had depression and suicidal thoughts. “A lot of people have depression and suicidal thoughts and don’t do anything like this,” Sledge said. “Blaming the crash on depression alone is wrong. This was way beyond mental illness.”

The rush to attribute the crash solely to depression disturbed others, as well.

It was too early “to discuss on the basis of incomplete information the possible role of a mental illness in the alleged decision of the copilot to crash the plane,” said the German Association for Psychiatry, Psychotherapy, and Psychosomatics, in a statement. “In the public discussion the impression is being wrongly conveyed that [people with] mental illnesses, in particular one of the most common, depression, represent a risk to the general population and that protective measures need to be taken against them.”

Stricter requirements for clinicians to override confidentiality and report mental illness to regulators or employers would only increase stigma and prevent treatment, said the association.

Several other air disasters—notably a 1997 crash in Indonesia, a 1999 EgyptAir crash off Nantucket Island, and a 2013 incident in Namibia—have been blamed on suicidal pilots, although investigators have often shied away from formally designating them as such, possibly for political reasons. The mysterious disappearance last year of Malaysia Airlines Flight 370 also led to speculation that a pilot intentionally sent the plane to its doom somewhere in the Indian Ocean. No trace of that plane has been found yet, so there is no evidence one way or the other about what caused its fate.

Such incidents are clearly rare and that safety record depends in part on vetting pilots for fitness.

The U.S. system to keep unstable and possibly dangerous people from flying airplanes generally functions well, said Sledge. “It doesn’t mean that people are flying who you don’t want flying, but I can tell you that they don’t fly for long.”

The key, said Sledge, is not merely passing or failing a physical or psychological test; it is the pilot’s “suitability” to fly a plane—a much more complex assessment. The focus of evaluation is not on mental illness but rather on the characteristics of a successful aviator. Besides technical skills, those include clear thinking, intelligence, good judgment, following flight rules and procedures, and the capacity to be innovative in the face of danger.

Historically, many civilian pilots in the United States gained experience flying military aircraft. Would-be U.S. Air Force pilots not only have to pass objective tests and screening but also subjective evaluations over several years, explained an Air Force official.

“[P]ilot trainees undergo extensive training that includes scrutiny by senior pilots,” said the official in response to an email. “After these individuals complete pilot training, they continue to be closely observed by operational leadership and peers in their community in addition to having regular medical evaluations by a flight surgeon.”

Civilian airlines are regulated by the Federal Aviation Administration (FAA). Airline pilots undergo a medical exam with an FAA-approved physician (called an aviation medical examiner, or AME) every 12 months (if they are under 40 years old) or every six months (if they are older). All AMEs have had special training in evaluating pilots.

“The FAA medical application form includes questions pertaining to the mental health of the pilot,” noted the agency in an email to Psychiatric News. “All existing physical and psychological conditions and medications must be disclosed.”

FAA rules state that pilots cannot have an “established medical history or clinical diagnosis” of a personality disorder, psychosis, bipolar disorder, or substance dependence. The last is covered in more detail than any other psychiatric condition.

If the AME believes that additional psychological testing is indicated, he or she can refer a pilot for further evaluation by a psychiatrist. These psychiatrists also have specialized training and are often pilots themselves, said Sledge, who has conducted about 200 such evaluations in his career. “So I’ve seen the worst in American aviation.”

Sledge suggested that there is also at least an informal system of crew members keeping an eye on each other’s behavior. A recent article in the New York Times recounted two cases in which the pilots’ erratic actions required intervention from copilots to safely continue their flights.

Both the Air Force and the FAA said they have provisions for returning to service a pilot grounded for mental health treatment.

“Flight surgeons work with mental health providers to ensure that the pilot receives timely, empirically validated treatments,” said the Air Force official. “After successful treatment [and] a period of observation by the flight surgeon, mental health provider, and operational commander, the pilot may be cleared to return to flying status.”

European airlines have depended less on pilots with military experience and thus aren’t vetted in the same way, said Sledge. However, the most significant difference between U.S. and European carriers—up until the Germanwings crash—was the two-person rule. After the September 11 hijackings, the United States required that two crew members had to be in the cockpit at all times, to better manage affairs in the cockpit if problems arose during the flight. That rule was discretionary in Europe and many airlines there decided to implement it only after the Germanwings crash. ■

The 2015 Guide for Aviation Medical Examiners can be accessed here.