Improving Aviation Safety: Insights from Dr. Joerg Siedenburg

1. What should we do differently ? Airlines view Dr. Jörg Siedenburg

2. Disclosure Information87thAnnual Scientific and Human Performance MeetingDr. Joerg Siedenburg MD I have the following financial relationships to disclose: • Stockholder in: Lufthansa • Employee of: Lufthansa Medical Department I will not discuss off-label use and/or investigational use in my presentation

3. General remarks position presented is not view of Lufthansa personal view as aeromedical expert

4. General remarks aviation is an ultrasafe system 2015 safest year in history of aviation safety with only 564 fatalities system failures extremely rare but catastrophic 2015 year with catastrophic event caused by medical incapacitation analysis of system vs. „scapegoat principle“

5. Onion model individual immediate environment supervision organisation regulator

6. General systemic remarks aeromedical system is a „self grounding system“ aeromedical system is a very effective self controlling system (like most other areas of aviation) legal actions not in its entirety performed by authorities - authorities rather audit procedures mutual trust required complex system - no „quick solutions“

7. Disposition in case of disorders aeromedical concerns • clinical features of disorder • adverse effects of meds / therapy waivers based on individual functional abilities intended activity experience kind of therapy realised in different ways, based on ICAO Annex 1, 1.2.4.9

8. „Flexibility standard“ 1.2.4.9 If medical Standards ... are not met, the appropriate Medical Assessment shall not be issued or renewed unless ...: a) accredited medical conclusion indicates that in special circumstances the applicant’s failure to meet any requirement, whether numerical or otherwise, is such that exercise ... not likely to jeopardize flight safety; b) due consideration to relevant ability, skill and experience of applicant and operational conditions c) the licence is endorsed with any special limitation or limitations ...

9. Aero-medical assessment (Regulation (EU) 1178/2011, Annex IV - Part-MED) MED.A.020 requires report of applicant to AME (decrease in medical fitness) MED.A.050 and MED.B.001 (a) in general require AME  referral to licensing authority MED.B.005 allows delegation to AeMC

10. Report to Licensing Authority 1.2.4.7 Having completed the medical examination of the applicant in accordance with Chapter 6, the medical examiners hall coordinate the results of the examination and submit a signed report, or equivalent, to the Licensing Authority, in accordance with its requirements, detailing the results of the examination and evaluating the findings with regard to medical fitness.

11. Report to Licensing Authority MED.A.025 (b) (4) ... submit report to include assesment result and copy of medical certificate to licensing authority

12. Medical confidentiality 1.2.4.10 Medical confidentiality shall be respected at all times.

13. Medical confidentiality MED.A.015 All persons involved in medical examination, assessment and certification shall ensure that medical confidentiality is respected at all times.

14. Medical confidentiality in Germany in light of history confidentiality in general and medical confidentiality in particular regarded of highest value with constitutional status reporting of personalised data to licensing authority would be a criminal act effective from APR 2015 pseudonymised reports required changes foreseen in line with MED.A.015, draft of changes of pertinent provisions envisaged

15. Safety management 1.2.4.2 Recommendation.— ...States should apply, as part of their State safety programme, basic safety management principles to medical assessment process, that as a minimum include: a) routine analysis of in-flight incapacitation events and medical findings during medical assessments to identify areas of increased medical risk; and b) continuous re-evaluation of the medical assessment process to concentrate on identified areas of increased medical risk.

16. Mental Health and Flying Ψ

17. G. Courbet, self portrait, 1844)

18. Sick leave in Germany (change (%)) 100 80 psychiatric 60 40 20 cardiovascular 0 musculo-sceletal -20 2006 2004 2008 2010 2000 2002 (source: BGF, 2011)

19. Mental health disorders in Occupational Medicine  11 % of sick leaves caused by of mental health disorders  every 7th day of sick leave by mhd  every 10th employee affected highest burden of cost of all diseases long duration of disease (in average 28 d in 2009 vs. 6 d in URI) increasing since 1991 by factor 2,5

20. Mental disorders  1/3 of population / a with mental disorder in D age 18 - 35 a 45 % (souce: Grefe C, Coach oder Couch, ZEIT28, 2013)

21. Mental disorders ~ 50 % of US young / middle aged adults mental disorder some time in their previous life ~ 19 % affective disorder ~ 10 % depression ~ 25 % fear / phobic disorder (souce: Kessler RC et al., 1994)

22. Causes for incapacitation (UK pilots, 2004) musculosceletal 18 % cardiovascular 14 % psychiatric 10 % (source: Evans et al, ASEM 2012)

23. 28 MAY 1987, Moscow Red Square

24. 27 MAR 2000, Selbstmordattentäter dringt in Cockpit ein (source: SächsZ, 02.06.15)

25. 28 JAN 2008

26. Jet Blue flight 191, 27 MAR 2012 Captain of a domestic flight from New York . Las Vegas displayed strange behaviour at controls - FO ushered him to toilet and locked cockpit door - Capt ran through cabin and cried about bomb, al Qaida and asked to pray  handcuffed by pax and flight attendants  diversion to Amarillo

27. Dr. Bellows

28. CMD common / minor mental disorders non-psychotic depressive symptoms anxiety somatic complaints (headache, lack of appetite, tremors, poor digestion) difficulties in concentrating and making decisions forgetfulness insomnia, fatigue irritability feelings of usefulness (souce: Feijo, 2013)

29. CMD common / minor mental disorders related to living conditions occupational stress factors (souce: Feijo, 2013)

30. CMD common / minor mental disorders stress factors in pilots staying away from home deprived of social and family life flying hours and rest days differ from life at home work overload lack of physical activity (souce: Feijo, 2013)

31. Mental health disorders mental health disorders are perceived as a taboo embarrassing diagnosis 90 % of patients with no sufficient treatment

32. Depression life time prevalence in general population 20 % (van der Kallen, 2012) life time prevalence in general US population 16 % (Wlliott RW, 2013)

33. Increase of mental disease and depression (D) prevalence (/ 10.000) 80 60 40 20 1995 2000 1990 2005 2010 (source: Barmer GEK 2011)

34. Depression # 1 in global burden of disease in adults 19 - 45 a in developed world (World Bank) 15 % of adults may experience clinical depression 20 % will not recover from index episode 70 - 80 % of rest at least one recurrence 15 % of depressive patients commit suicide 60 % of suicides caused by depression (after Collins Howgill PC)

35. Depression: recurrence rate within 5 a after first episode: 50 % within 5 a after two episodes: 70 % within 5 a after three episodes: 90 % (source: Elliott R, 2013)

36. Toolbox: questions for diagnosis Have you suffered from low spirits / melancholy, depression or hopelessness in the past month? Have you suffered from loss of interest or joylessness? 2 x “no”  96 % probability no depression > 1 x “yes”  50 % probability depression (Whooley MA, Simon GE (2007): Managing depression in medical outpatients. NEJM 153: 127 - 132)

37. Depression: aeromedical concerns impacts on cognitive functioning (speed mental processing ↓, psychomotor retardation, mild attentional deficits, drive and initiation ↓, memory problems, learning for visual & verbal material ↓, language, perception, spatial abilities, motivation, organisation) impacts on effective functioning (source: Elliott R, 2013)

38. Probable pilot suicides (extended suicides, aircraft assisted pilot suicides) • 1982 Japan Airlines DC-8 24 dead • 1994 Royal Air Maroc ATR 42 44 dead • 1997 Silk Air 737-700 104 dead • 1999 Air Botswana 1 dead • 1999 Egypt Air 767 217 dead • Silk Air pilot • Tsu Way Ming (after Collins Howgill PC)

39. 2013 LAM Embraer 190 33 dead • 2014 MH 370 B777 239 dead • 2015 UA 9525 A 320 150 dead

40. Aircraft assisted suicides 0,33 % of fatal aviation accidents after suspective accidents  psychological autopsy (besides physical ~) 2 - 4 % car assisted suicide in road traffic accidents real number 2 times as high estimated 22 % only communicate intention to health personnel before 63 % someone knew of suicidal ideation risk factors: societal factors cultural factors personal risk factors: earlier suicide attempt major depressive episode alcohol abuse

41. Factors associated with suicide / homicide-suicide involving aircraft no single factor legal and financial crises occupational conflict mental illness relationship stressors drugs and / or alcohol (only suicide) (source: Kenedi C et al , AMHP 84; 4: 388 - 396)

42. Protective factors in pilots lower rate of suicides in pilots than genral population (13 : 100.000) screening for mental, significant physical illness, substance abuse demonstration of coping, and problem solving skills no prior suicide attempts sense of community (other pilots and other staff) (source: Kenedi C et al , AMHP 84; 4: 388 - 396)

43. Protective factors in cockpit 2 flight crew in cockpit protective most homicide - suicides in commercial aircraft while alone (source: Kenedi C et al , AMHP 84; 4: 388 - 396)

44. Factors associated with suicide / homicide-suicide involving aircraft mental disease no defining contributor mental disorders not necessarily disqualifying (e.g. depression / suicicde attempt in NZ and AUS) (source: Kenedi C et al , AMHP 84; 4: 388 - 396)

45. Problems current regulations give little guidance about dealing with mental health persons with psychiatric disorders fear stigmatisation fear of loosing livelihood  patients hesitant to seek help cordial small talk may reveal hints

46. MED.B.055PSYCHIATRY no established medical history / clinical diagnosis of psychiatric disease / disability / condition / disorder, acute / chronic, congenital / acquired likely to interfere with safe flying 46

47. mental / behavioural disorder due to alcohol / other use / abuse of psychotropic substance  unfit pending successful treatment recovery and freedom from substance use satisfactory psychiatric evaluation  Class 1 referral to licensing authority Class 2 assessed in consultation with lic. auth. 47

48. satisfactory psychiatric evaluation before fit assessment mood disorder neurotic disorder personality disorder mental / behavioural disorder 48

49. unfit history of single / repeated acts of deliberate self-harm satisfactory psychiatric evaluation before fit assessment can be considered 49

50. Aero-medical assessment of conditions Class 1  referral to licensing authority Class 2  assessment in consultation with licensing authority 50