Assessing aeromedical risk: a three-dimensional risk matrix approach

Abstract

Early aeromedical risk i was based on aeromedical standards designed to eliminate individuals ii from air operations with any identifiable medical risk, and led to frequent medical disqualification. The concept of considering aeromedical risk as part of the spectrum of risks that could lead to aircraft accidents (including mechanical risks and human factors) was first proposed in the 1980s and led to the development of the 1% rule which defines the maximum acceptable risk for an incapacitating medical event as 1% per year (or 1 in 100 person-years) to align with acceptable overall risk in aviation operations. Risk management has subsequently evolved as a formal discipline, incorporating risk assessment as an integral part of the process. Risk assessment is often visualised as a risk matrix, with the level of risk, urgency or action required defined for each cell, and colour-coded as red, amber or green depending on the overall combination of risk and consequence. This manuscript describes an approach to aeromedical risk management which incorporates risk matrices and how they can be used in aeromedical decision-making, while highlighting some of their shortcomings.

An introduction to aviation cardiology

“…This area is complex and hotly debated and is addressed in detail in the associated paper on cardiovascular risk assessment in aircrew. 10 …”

“… *Exercise stress ECG test is not recommended as a solely investigative tool for assessment of significant coronary artery disease in aircrew. 10 …”

“…This is one reason for the development of the NATO aviation cardiology working group (HFM-251) including a cardiac surgeon, general internal medicine physicians, flight surgeons and cardiologists, and the publication of this article and those related to it. 10–18 In this context, expert consensus is likely to be the best that can be achieved at present (given the numbers likely to be required for any other type of evidence to be produced); however, it is hoped that further research in this area will be forthcoming, such as that on the role of CT coronary angiography (CTCA) versus coronary artery calcium score (CACS) in the assessment of aircrew with suspected coronary artery disease. 38 While these studies have small cohorts, they still inform the decision-making process and policies that in turn ensure that aircrew can be returned to flying where possible or grounded if this is appropriate.…”

“…This manuscript describes the current medical regulatory framework for aircrew; aircrew roles in the civil and military aviation profession; the types of aircraft and aviation environment that must be understood when managing aircrew with CVD; the regulatory bodies involved in aircrew licensing and the risk assessment processes that are used in aviation medicine to determine the suitability of aircrew to fly with medical (and specifically cardiovascular) disease; and the ethical, occupational and clinical tensions that exist when managing patients with CVD who are also professional aircrew. It serves as an introduction to the subsequent papers on risk assessment of aircrew, 10 screening of aircrew 11 and specific articles that address coronary artery disease (both pre- and post-intervention), 12 13 electrical abnormalities of the heart, 14 valvular disease, 15 heart muscle disease, 16 congenital heart disease 17 and cardiac intervention 18 in aircrew. This article does not address cabin crew or passengers.…”

Management of established coronary artery disease in aircrew without myocardial infarction or revascularisation

“…This assessment must incorporate angiographic findings, a detailed risk assessment and a nuanced management plan that must include aggressive control of the atherosclerotic disease process to ensure safety of flight. 2 Current published guidelines regarding CAD treatment should always be followed initially for all aircrew however, there may be occupational considerations that require a more aggressive treatment approach for which aircrew consent is required. For example, a single stenosis >70% in an asymptomatic patient can either be treated medically or revascularised based on current guidelines but only the latter would be acceptable for a pilot to return to flight duties, to mitigate the longer term risks, including sudden incapacitation.…”