Testimony of Mitchell A. Garber, M.D., M.P.H., M.S.M.E.
Medical Officer
National Transportation Safety Board
Before the
Committee on Transportation and Infrastructure
Subcommittee on Aviation
U.S. House of Representatives
“FAA’s Oversight of Falsified Airman Medical Certificate Applications”
Washington, DC
July 17, 2007

Good morning Chairman Costello, Ranking Member Petri, and Members of the Subcommittee.  Thank you for allowing me the opportunity to present testimony on behalf of the National Transportation Safety Board regarding FAA’s Oversight of Falsified Airman Medical Certificate Applications.  It is a privilege to represent an agency that is dedicated to the safety of the traveling public.

On June 17, 2002, a commercial-rated pilot performing wolf survey flights under contract to the Michigan Department of Natural Resources descended at high speed into terrain.  Examination of the wreckage revealed no anomalies.  The pilot had multiple serious medical conditions, including coronary heart disease requiring angioplasty and bypass surgery, disease of his heart valves, congestive heart failure, abnormal heart rhythms and diabetes requiring insulin and oral medication.  The pilot and his personal physician--who had flown the pilot back from his hospitalization following his initial heart attack and who later became his Aviation Medical Examiner (AME) for many years--had concealed from the Federal Aviation Administration (FAA) information regarding the pilot's conditions on seven applications for Airman Medical Certificates.  The pilot’s physician had denied knowing the pilot when the FAA was investigating a report that the physician was treating him for these conditions.  At the time of the accident, the pilot’s physician had been decertified as an AME for failure to complete required training, and the pilot did not have a current medical certificate, having been deferred for certification by a new AME who noted some abnormal heart rhythms on examination.  The Safety Board concluded that the accident was caused by the incapacitation of the pilot and that a contributing factor was the pilot and his physician providing false information on the pilot's medical applications

I would like to review some data regarding the extent to which we see issues such as these in our investigations.  A recent staff review of over 20,000 aviation accidents investigated since 1995 found 327 in which impairment, incapacitation, or a medical condition were identified as causes or factors: 

• 61 involved over-the-counter medications, primarily antihistamines like diphenhydramine, also commonly known by the trade name Benadryl;
• 84 involved prescription medications (primarily anti-anxiety medications, painkillers, and a few older antidepressant medications and anti-psychotic medications);
• 52 involved illicit substances and 73 involved alcohol;
• 106 involved some sort of identified or suspected medical condition; of these –
  • 15 had no current medical certificate (2 were gliders and none was required);
  • In 13 with a current medical certificate, it was established that the pilot was not aware of the condition;
  • In 38 with a current medical certificate, it was not established that the pilot was either aware or unaware of symptoms of the condition prior to the flight (this includes 21 accidents attributed to an acute condition – heart attack, stroke, gastrointestinal distress, etc.);
  • In 40 with a current medical certificate, it was established that the pilot was aware of the condition:
    • In 10 of these, the condition had been fully reported to the FAA;
    • In 26 of these, the pilots had either not reported any information or had reported incomplete information regarding their condition to the FAA at the time of their most recent medical certificate. 

It is important to note that these numbers are certainly an underestimate of the extent to which this issue is involved in accidents.  The NTSB judiciously uses its subpoena authority to obtain personal medical records only when evidence already exists--usually from autopsy or toxicology reports or from the nature of the accident--to suggest medical involvement.  In many cases, there is insufficient evidence available to completely evaluate the possibility of impairment or incapacitation.

The NTSB is fortunate to benefit from the resources of the FAA toxicology laboratory at the Civil Aerospace Medical Institute, likely the finest toxicology laboratory in the world for analysis of specimens from accident investigations.  We are, therefore, confident that we are finding most reasonably detectable medications and other drugs of relevance in samples submitted to the laboratory, and we are often able to determine that the pilot used a specific substance in the hours or days preceding the accident. 

It is our experience, confirmed by FAA studies, that most medications found on toxicology evaluation, even those routinely approved by the FAA for use by pilots, are not reported on the most recent applications for airman medical certificates of accident-involved pilots.  It is frequently not possible to definitively determine when these medications were started, or what the condition was for which they were taken.  Based on the cases in which such determinations could be made, however, it seems likely that the use of many if not most of these medications was concealed from the FAA.  In most cases, the medications themselves are unlikely to have impaired the pilot, and were not determined to be related to the cause of the accident.

Though it was not possible in most cases to determine the reasons for which medications were used, the medications that were found to be relevant to accident causes were most frequently those commonly utilized for the relatively short-term treatment of conditions such as allergy symptoms, anxiety, and pain. 

In a number of cases, potentially addictive prescription medications were found at levels well in excess of normal therapeutic concentrations, strongly suggesting the possibility of substance dependence.  Alcohol and illicit substances are also found in more than a third of the accidents deemed to result from impairment or incapacitation.  The alcohol levels in alcohol-involved accidents are most commonly many times higher than the FAA’s limit for operating an aircraft, strongly suggesting the possibility of alcohol dependence in most alcohol-involved accidents.  The NTSB has identified a number of alcohol or illicit substance related accidents in which prior evidence of substance dependence was available to the FAA.

The Safety Board notes that it is, of course, possible for a pilot to fly without medical certification, as was the case for the pilot in the accident presented, even though he was being employed by a State agency at the time of his accident.  Ramp checks on pilots not involved in commercial passenger operations are infrequent, and FAA inspectors have limited authority to physically enforce flight restrictions at any rate.  Pilots under many circumstances, such as balloon pilots, glider pilots, and now sport pilots, are able to fly without obtaining a medical certificate. 

The Safety Board also notes that it is often difficult, even with the Board’s investigative authority, to definitively identify cases of falsification on application for medical certificates.  It is necessary to first identify the existence of a condition or medication, establish that it would have resulted in substantially different answers on the pilot’s most recent application for medical certificates, and prove that the condition or medication was present at the time of the most recent application, as there is no requirement for reporting such conditions or medications in between examinations.  

The FAA permits anonymous reporting of medical conditions in pilots and frequently conducts independent investigations of such reports, as in the case for the accident presented.  As noted for this case, however, it is still possible for the condition to be concealed, particularly when a physician can be persuaded to lie on behalf of the pilot.  Even when the FAA becomes aware of such falsification, action is frequently limited to the revocation of certifications issued, rather than criminal prosecution, for which resources are not always available. 

The Safety Board has been concerned for many years regarding the inappropriate use of certain medications by pilots and other vehicle operators, and in 2000 issued comprehensive recommendations on this topic to the Department of Transportation (DOT), the Food and Drug Administration (FDA) and modal agencies to improve information provided to such operators regarding the use of appropriate medications while engaged in vehicle operations (including
I-00-1 through –5 and A-00-4 through –6).  Although some modal agencies have taken certain responsive actions, the overall response to date from the DOT and the FDA has been limited and the majority of the recommendations on this topic have not been implemented.

The Safety Board has also noted that in many accidents due to a pilot’s intoxication by alcohol, illicit substances, or large amounts of potentially addictive medications, the FAA was or should have been aware of information that would have led them to conclude that the pilot was substance dependent and would have restricted issuance of a medical certificate.  In particular, the NTSB has noted a number of instances in which the FAA did not request details from identified DUI convictions in order to determine the circumstances of the violations.  Additionally, the Board has found that information available to the FAA on potentially substance dependent pilots was often not provided to individuals evaluating the pilots for possible substance dependence.  Furthermore, the Board is concerned that, unlike other chronic conditions, the FAA does not routinely require that pilots with substance dependence be followed for the condition for the period that they hold a medical certificate.  The Board has recently issued several recommendations (A-07-41 to -43) to address these deficiencies.

Finally, the Safety Board notes that, unlike many other countries, and inconsistent with International Civil Aviation Organization recommendations, there is no requirement for the reporting of medical conditions in between periodic examinations.  As noted previously in this testimony, this significantly increases the complexity of establishing that a condition was concealed from the FAA, since it may not have become apparent until after the most recent medical examination.  The FAA has recently proposed increasing the interval between medical examinations for certain pilots, and the Safety Board has noted in its comments to that NPRM that a reporting requirement between examinations would be desirable.