A23-01 - The Department of Transport establish a framework for routine review and improvement to the Handbook for Civil Aviation Medical Examiners to ensure it contains the most effective screening tools for assessing medical conditions such as cardiovascular health issues.
Transport Canada’s response to Aviation Safety Recommendation A23-01
Through this investigation, the Transportation Safety Board of Canada (TSB) revealed two safety issues related to ensuring that medical issues that could impact flight safety are identified and addressed.
First, on January 11, 2023, the TSB issued an Aviation Safety Advisory LetterFootnote 1 to Transport Canada Civil Aviation (TCCA) indicating that the investigation found that not all physicians are aware of the requirement to inform TC about medical conditions and/or prescribed medications that could affect the safe operation of an aircraft.
The Department responded Footnote 2 on January 19, 2023, stating that Transport Canada Civil Aviation Medicine (CAM) coordinated with the Canadian Medical Association (CMA) to increase awareness of the mandatory reporting obligation outlined by the Aeronautics ActFootnote 3 . Specifically, CAM updated the Aviation Medicine section of the CMA Driver’s Guide featuring an up-front “alert box”Footnote 4 that prominently reminds physicians of their mandatory reporting obligations under the Aeronautics Act. In addition, it is clearly indicated for a general practitioner, who is not otherwise a CAME, how to report a potential condition to TC CAM. Given the broad distribution of the CMA Driver’s Guide, this will be a high-impact and influential means of communicating the mandatory reporting obligation to Canadian physicians.
Second, as part of the final investigation report, the TSB issued the subject recommendation to address a related safety deficiency about the process for carrying out regular update of guidance for assessing medical conditions such as cardiovascular issues and suggested that Transport Canada (TC) establish a framework to review and update the Handbook for Civil Aviation Medical ExaminersFootnote 5 (CAMEs).
TC agrees with the recommendation and the strategy to mitigate this safety deficiency is two-fold.
In the first part of this response, the Department will outline how the Civil Aviation Documentation Framework Footnote 6 allows routine reviews and improvement to the CAMEs Handbook to ensure that it contains the most effective screening tools for assessing medical conditions. In the second part, TC will outline the measures in place and plans to assess cardiovascular health risks and issues which could have an impact on the safe operation of an aircraft.
- 1. Document Framework and Handbook Update
TC CAM has been actively updating the content of the Handbook for CAMEs (TP13312) since 2019. The process of updating the Handbook for CAMEs involves repealing and replacing sections of the Handbook with the corresponding Staff Instructions (SI), as they go into force. Eventually, the Handbook will be replaced in its entirety by SI documents.
The SI format Footnote 7 is a standardized TC departmental document format chosen to facilitate use of and future regular updating of aeromedical policy topics. SIs provide TCCA employees with specific information and procedures to standardize the delivery of the Civil Aviation Program. They are consistent with departmental principles, policies, and regulatory requirements and are normally national in scope. Also, the SI format supports a modular (i.e., single topic) approach to treating aeromedical subjects, which is generally how medical references manage topics. This format also makes drafting, publication, and updating faster and easier. The TP format (on which the actual Handbook is built) tends to result in a monolithic “textbook” that is not currently the standard for online medical resources and makes resources longer to produce.
SIs are also available through the Civil Aviation Reference CentreFootnote 8. However, TC CAM is working with Digital services and Web services to provide both a CAME and public facing library for ease of reference. TC CAM also circulate SIs by email to CAMEs and any member of the public requesting them, in the meantime.
The first aeromedical SI Footnote 9 was effective as of March 12, 2019 and established the foundational principles of aeromedical decision-making for TC CAM and CAMEs.
TCCA also recently issued other aeromedical SIs that either add-to or update Handbook content:
- SI 424-001 – Aviation Medical Review Board Terms of ReferenceFootnote 10 – effective 12 March 2019.
- SI 404-002 – Civil Aviation Medicine Cannabis PolicyFootnote 11 – effective 03 June 2019.
- SI 404-003 – Civil Aviation Medicine Credentialing RequirementsFootnote 12 – effective 01 January 2020; and,
- SI 424-002 – Substance Use DisorderFootnote 13 – effective 01 March 2020 with second update effective 03 June 2022;
TCCA have other SIs currently in the final stages of approval that will add or update the Handbook:
- “Depression and Anti-Depressant Medications”
- “Attention Deficit / Hyperactivity Disorder”
- “Medications and Aviation Medical Certification”
Ultimately, this collection of SIs will provide CAMEs with all the necessary and relevant information regarding TC CAM’s policies based on the most recent screening tools used to assess various medical conditions that could have an impact on the safe operation of an aircraft.
- 2. Cardiovascular Health Issues Assessment
As noted above, the first foundational aeromedical staff instruction SI 404-001 Footnote 14 was published in 2019. It describes the framework for aeromedical risk assessment (RA) and risk management (RM) for use in the medical certification process including cardiovascular risk assessment. The process is based on one developed for astronauts aboard the International Space Station developed, in part, by a pre eminent Canadian aeromedical cardiovascular expert.
SI 404-001 reminds that all flight crew (i.e., pilot and flight engineer) and ATC licenses and permits must be validated by a current Medical Certificate (MC) that indicates that the holder meets the medical requirements and standards established by TC CAM. For applicants who do not meet the required standards, CARs 424.05 allows for the application of flexibility that permits the issuance of a MC where it is in the public interest and not likely to affect aviation safety. The SI outlines how the principles of aeromedical RA/RM are to be applied in the application of flexibility.
To keep up to date with medical advances in screening procedures, TC CAM intends to update the cardiovascular guidance currently in the Handbook (TP13312), along with the rest of the Handbook content. This update will reflect the latest guidance from a variety of sources, including the Canadian Cardiovascular Society, but also other aeromedical assessment best practices.
It should be noted that written guidance in medicine tends to lag best practices, especially with the exponential growth being seen in medical knowledge. This is a phenomenon that medicine in general is working hard to manage, given the unprecedented growth of medical knowledge and rapid evolution of best practices. The SI format was selected to replace the single handbook for CAMEs to provide a more flexible means to update guidance on specific topics as the need arises.
It is important to emphasize that cardiovascular risk in aviation is the original and one of the most well characterized and quantifiable risks in aviation medicine. Indeed, the International Civil Aviation organization (ICAO) Footnote 15 recognizes an acceptable upper threshold of risk for medical events of up to 2% per year; it is therefore impossible to achieve a zero-risk environment.
In the meantime, TC CAMEs – appointed by the Minister of Transport to conduct aviation medical examinations – are physicians licensed in their respective provinces and territories. They are expected both by TC and their Provincial and Territorial medical regulators to apply the most current medical guidelines, including those published by the Canadian Cardiovascular Society Footnote 16 for cardiovascular health assessment. Finally, TC CAM has a consultant Cardiologist on the Aviation Medical Review Board Footnote 17 (AMRB), and any files involving cardiovascular issues are reviewed by a cardiovascular specialist on an individual basis, with the most current cardiovascular guidelines being applied.