MED.B.010 Cardiovascular System
Regulation (EU) 2019/27
(a) Examination
(1) A standard 12-lead resting electrocardiogram (ECG) and report shall be completed when clinically indicated and at the following moments:
(i) for a class 1 medical certificate, at the initial examination, then every 5 years until age 30, every 2 years until age 40, annually until age 50, and at all revalidation or renewal examinations thereafter;
(ii) for a class 2 medical certificate, at the initial examination, at the first examination after age 40 and then at the first examination after age 50, and every 2 years thereafter.
(2) An extended cardiovascular assessment shall be required when clinically indicated.
(3) For a class 1 medical certificate, an extended cardiovascular assessment shall be completed at the first revalidation or renewal examination after age 65 and every 4 years thereafter.
(4) For a class 1 medical certificate, estimation of serum lipids, including cholesterol, shall be required at the initial examination, and at the first examination after having reached the age of 40.
(b) Cardiovascular System – General
(1) Applicants for a class 1 medical certificate with any of the following medical conditions shall be assessed as unfit:
(i) aneurysm of the thoracic or supra-renal abdominal aorta, before surgery;
(ii) significant functional or symptomatic abnormality of any of the heart valves;
(iii) heart or heart/lung transplantation.;
(iv) symptomatic hypertrophic cardiomyopathy.
(2) Before further consideration is given to their application, applicants for a class 1 medical certificate with a documented medical history or diagnosis of any of the following medical conditions shall be referred to the medical assessor of the licensing authority:
(i) peripheral arterial disease before or after surgery;
(ii) aneurysm of the thoracic or supra-renal abdominal aorta after surgery;
(iii) aneurysm of the infra-renal abdominal aorta before or after surgery;
(iv) functionally insignificant cardiac valvular abnormalities;
(v) after cardiac valve surgery;
(vi) abnormality of the pericardium, myocardium or endocardium;
(vii) congenital abnormality of the heart, before or after corrective surgery;
(viii) vasovagal syncope of uncertain cause;
(ix) arterial or venous thrombosis;
(x) pulmonary embolism;
(xi) cardiovascular condition requiring systemic anticoagulant therapy.
(3) Applicants for a class 2 medical certificate with an established diagnosis of one of the conditions specified in points (1) and (2) shall be evaluated by a cardiologist before they may be assessed as fit, in consultation with the medical assessor of the licensing authority.
(4) Applicants with cardiac disorders other than those specified in points (1) and (2) may be assessed as fit subject to satisfactory cardiological evaluation.
(c) Blood Pressure
(1) Applicants’ blood pressure shall be recorded at each examination.
(2) Applicants whose’s blood pressure is not within normal limits shall be further assessed with regard to their cardiovascular condition and medication with a view to determining whether they are to be assessed as unfit in accordance with points (3) and (4).
(3) Applicants for a class 1 medical certificate with any of the following medical conditions shall be assessed as unfit:
(i) symptomatic hypotension;
(ii) blood pressure at examination consistently exceeding 160 mmHg systolic or 95 mmHg diastolic, with or without treatment.
(4) Applicants who have commenced the use of medication for the control of blood pressure shall be assessed as unfit until the absence of significant side effects has been established.
(d) Coronary Artery Disease
(1) Before further consideration is given to their application, applicants for a class 1 medical certificate with any of the following medical conditions shall be referred to the medical assessor of the licensing authority and undergo cardiological evaluation to exclude myocardial ischaemia:
(i) suspected myocardial ischaemia;
(ii) asymptomatic minor coronary artery disease requiring no anti-anginal treatment.
(2) Before further consideration is given to their application, applicants for a class 2 medical certificate with any of the medical conditions set out in point (1) shall undergo satisfactory cardiological evaluation.
(3) Applicants with any of the following medical conditions shall be assessed as unfit:
(i) myocardial ischaemia;
(ii) symptomatic coronary artery disease;
(iii) symptoms of coronary artery disease controlled by medication.
(4) Applicants for the initial issue of a class 1 medical certificate with a medical history or diagnosis of any of the following medical conditions shall be assessed as unfit:
(i) myocardial ischaemia;
(ii) myocardial infarction;
(iii) revascularisation or stenting for coronary artery disease.
(5) Before further consideration is given to their application, applicants for a class 2 medical certificate who are asymptomatic following myocardial infarction or surgery for coronary artery disease shall undergo satisfactory cardiological evaluation, in consultation with the medical assessor of the licensing authority. Such applicants for the revalidation of a class 1 medical certificate shall be referred to the medical assessor of the licensing authority.
(e) Rhythm/Conduction Disturbances
(1) Applicants with any of the following medical conditions shall be assessed as unfit:
(i) symptomatic sinoatrial disease;
(ii) complete atrioventricular block;
(iii) symptomatic QT prolongation;
(iv) an automatic implantable defibrillating system;
(v) a ventricular anti-tachycardia pacemaker.
(2) Before further consideration is given to their application, applicants for a class 1 medical certificate havingany significant disturbance of cardiac conduction or rhythm, including any of the following, shall be referred to the medical assessor of the licensing authority:
(i) disturbance of supraventricular rhythm, including intermittent or established sinoatrial dysfunction, atrial fibrillation and/or flutter and asymptomatic sinus pauses;
(ii) complete left bundle branch block;
(iii) Mobitz type 2 atrioventricular block;
(iv) broad and/or narrow complex tachycardia;
(v) ventricular pre-excitation;
(vi) asymptomatic QT prolongation;
(vii) Brugada pattern on electrocardiography.
(3) Before further consideration is given to their application, applicants for a class 2 medical certificate with any of the medical conditions specified in point (2) shall undergo satisfactory cardiological evaluation, in consultation with the medical assessor of the licensing authority.
(4) Applicants with any of the following medical conditions may be assessed as fit subject to satisfactory cardiological evaluation and in the absence of any other abnormality:
(i) incomplete bundle branch block;
(ii) complete right bundle branch block;
(iii) stable left axis deviation;
(iv) asymptomatic sinus bradycardia;
(v) asymptomatic sinus tachycardia;
(vi) asymptomatic isolated uniform supra-ventricular or ventricular ectopic complexes;
(vii) first degree atrioventricular block;
(viii) Mobitz type 1 atrioventricular block.
(5) Applicants with a medical history of any of the following medical conditions shall undergo satisfactory cardiovascular evaluation before they may be assessed as fit:
(i) ablation therapy;
(ii) pacemaker implantation.
Such applicants for a class 1 medical certificate shall be referred to the medical assessor of the licensing authority. Such applicants for a class 2 medical certificate shall be assessed in consultation with the medical assessor of the licensing authority.
AMC1 MED.B.010 Cardiovascular system
ED Decision 2019/002/R
(a) Examination
Exercise electrocardiography
An exercise ECG when required as part of a cardiovascular assessment should be symptom limited and completed to a minimum of Bruce Stage IV or equivalent.
(b) General
(1) Cardiovascular risk factor assessment
(i) Serum lipid estimation is case finding and significant abnormalities should be reviewed, investigated and supervised by the AeMC or AME in consultation with the medical assessor of the licensing authority.
(ii) Applicants with an accumulation of risk factors (smoking, family history, lipid abnormalities, hypertension, etc.) should undergo a cardiovascular evaluation by the AeMC or AME, if necessary in consultation with the medical assessor of the licensing authority.
(2) Cardiovascular assessment
(i) Reporting of resting and exercise electrocardiograms should be by the AME or an accredited specialist.
(ii) The extended cardiovascular assessment should be undertaken at an AeMC or may be delegated to a cardiologist.
(c) Peripheral arterial disease
If there is no significant functional impairment, a fit assessment may be considered provided:
(1) applicants without symptoms of coronary artery disease have reduced any vascular risk factors to an appropriate level;
(2) applicants should be on appropriate secondary prevention treatment;
(3) exercise electrocardiography is satisfactory. Further tests may be required which should show no evidence of myocardial ischaemia or significant coronary artery stenosis.
(d) Aortic aneurysm
(1) Applicants with an aneurysm of the infra-renal abdominal aorta of less than 5 cm in diameter may be assessed as fit before surgery, with an OML subject to satisfactory evaluation by a cardiologist. Follow-up by ultra-sound scans or other imaging techniques, as necessary, should be determined by the medical assessor of the licensing authority.
(2) Applicants may be assessed as fit with an OML after surgery for an aneurysm of the thoracic or abdominal aorta if the blood pressure and cardiovascular evaluation is satisfactory. Regular evaluations by a cardiologist should be carried out.
(e) Cardiac valvular abnormalities
(1) Applicants with previously unrecognised cardiac murmurs should undergo evaluation by a cardiologist and assessment by the medical assessor of the licensing authority. If considered significant, further investigation should include at least 2D Doppler echocardiography or equivalent imaging.
(2) Applicants with minor cardiac valvular abnormalities may be assessed as fit. Applicants with significant abnormality of any of the heart valves should be assessed as unfit.
(3) Aortic valve disease
(i) Applicants with a bicuspid aortic valve may be assessed as fit if no other cardiac or aortic abnormality is demonstrated. Follow-up with echocardiography, as necessary, should be determined by the medical assessor of the licensing authority.
(ii) Applicants with aortic stenosis may be assessed as fit provided the left ventricular function is intact and the mean pressure gradient is less than 20 mmHg. Applicants with an aortic valve orifice with indexation on the body surface of more than 0.6 cm2/m2 and a mean pressure gradient above 20 mmHg, but not greater than 50 mmHg, may be assessed as fit with an OML. Follow-up with 2D Doppler echocardiography, as necessary, should be determined by the medical assessor of the licensing authority in all cases. Alternative measurement techniques with equivalent ranges may be used. Regular evaluation by a cardiologist should be considered. Applicants with a history of systemic embolism or significant dilatation of the thoracic aorta should be assessed as unfit.
(iii) Applicants with trivial aortic regurgitation may be assessed as fit. A greater degree of aortic regurgitation should require an OML. There should be no demonstrable abnormality of the ascending aorta on 2D Doppler echocardiography. Follow-up, as necessary, should be determined by the medical assessor of the licensing authority.
(4) Mitral valve disease
(i) Asymptomatic applicants with an isolated mid-systolic click due to mitral leaflet prolapse may be assessed as fit.
(ii) Applicants with rheumatic mitral stenosis should normally be assessed as unfit.
(iii) Applicants with minor regurgitation may be assessed as fit. Periodic cardiological review should be determined by the medical assessor of the licensing authority.
(iv) Applicants with moderate mitral regurgitation may be considered as fit with an OML if the 2D Doppler echocardiogram demonstrates satisfactory left ventricular dimensions and satisfactory myocardial function is confirmed by exercise electrocardiography. Periodic cardiological review should be required, as determined by the medical assessor of the licensing authority.
(v) Applicants with evidence of volume overloading of the left ventricle demonstrated by increased left ventricular end-diastolic diameter or evidence of systolic impairment should be assessed as unfit.
(f) Valvular surgery
Applicants who have undergone cardiac valve replacement or repair should be assessed as unfit. A fit assessment may be considered in the following cases:
(1) Mitral leaflet repair for prolapse is compatible with a fit assessment, provided post-operative investigations reveal satisfactory left ventricular function without systolic or diastolic dilation and no more than minor mitral regurgitation.
(2) Asymptomatic applicants with a tissue valve or with a mechanical valve who, at least 6 months following surgery, are taking no cardioactive medication may be considered for a fit assessment with an OML. Investigations which demonstrate normal valvular and ventricular configuration and function should have been completed as demonstrated by:
(i) a satisfactory symptom limited exercise ECG. Myocardial perfusion imaging/stress echocardiography should be required if the exercise ECG is abnormal or any coronary artery disease is suspected;
(ii) a 2D Doppler echocardiogram showing no significant selective chamber enlargement, a tissue valve with minimal structural alteration and a normal Doppler blood flow, and no structural or functional abnormality of the other heart valves. Left ventricular fractional shortening should be normal.
Follow-up with exercise ECG and 2D echocardiography, as necessary, should be determined by the medical assessor of the licensing authority.
(3) Where anticoagulation is needed after valvular surgery, a fit assessment with an OML may be considered if the haemorrhagic risk is acceptable and the anticoagulation is stable. Anticoagulation should be considered stable if, within the last 6 months, at least 5 international normalised ratio (INR) values are documented, of which at least 4 are within the INR target range. The INR target range should be determined by the type of surgery performed.
(g) Thromboembolic disorders
Applicants with arterial or venous thrombosis or pulmonary embolism should be assessed as unfit. A fit assessment with an OML may be considered after a period of stable anticoagulation as prophylaxis, after review by the medical assessor of the licensing authority. Anticoagulation should be considered stable if, within the last 6 months, at least 5 INR values are documented, of which at least 4 are within the INR target range and the haemorrhagic risk is acceptable. In cases of anticoagulation medication not requiring INR monitoring, a fit assessment with an OML may be considered after review by the medical assessor of the licensing authority after a stabilisation period of 3 months. Applicants with pulmonary embolism should also be evaluated by a cardiologist. Following cessation of anticoagulant therapy, for any indication, applicants should undergo a re-assessment by the medical assessor of the licensing authority.
(h) Other cardiac disorders
(1) Applicants with a primary or secondary abnormality of the pericardium, myocardium or endocardium should be assessed as unfit. A fit assessment may be considered following complete resolution and satisfactory cardiological evaluation which may include 2D Doppler echocardiography, exercise ECG and/or myocardial perfusion imaging/stress echocardiography and 24-hour ambulatory ECG. Coronary angiography may be indicated. Frequent review and an OML may be required after fit assessment.
(2) Applicants with a congenital abnormality of the heart should be assessed as unfit. Applicants following surgical correction or with minor abnormalities that are functionally unimportant may be assessed as fit following cardiological evaluation. No cardioactive medication is acceptable. Investigations may include 2D Doppler echocardiography, exercise ECG and 24-hour ambulatory ECG. The potential hazard of any medication should be considered as part of the assessment. Particular attention should be paid to the potential for the medication to mask the effects of the congenital abnormality before or after surgery. Regular cardiological evaluations should be carried out.
(i) Syncope
(1) In the case of a single episode of vasovagal syncope which can be explained and is compatible with flight safety, a fit assessment may be considered.
(2) Applicants with a history of recurrent vasovagal syncope should be assessed as unfit. A fit assessment may be considered after a 6-month period without recurrence, provided cardiological evaluation is satisfactory. Such evaluation should include:
(i) a satisfactory symptom limited 12 lead exercise ECG to Bruce Stage IV, or equivalent. If the exercise ECG is abnormal, myocardial perfusion imaging/stress echocardiography or equivalent test should be carried out;
(ii) a 2D Doppler echocardiogram showing neither significant selective chamber enlargement nor structural or functional abnormality of the heart, valves or myocardium;
(iii) a 24-hour ambulatory ECG recording showing no conduction disturbance, complex or sustained rhythm disturbance or evidence of myocardial ischaemia.
(3) A tilt test, or equivalent, carried out to a standard protocol showing no evidence of vasomotor instability may be required.
(4) Neurological review should be required.
(5) An OML should be required until a period of 5 years has elapsed without recurrence. The medical assessor of the licensing authority may determine a shorter or longer period of OML according to the individual circumstances of the case.
(6) Applicants who experienced loss of consciousness without significant warning should be assessed as unfit.
(j) Blood pressure
(1) The diagnosis of hypertension should require cardiovascular evaluation to include potential vascular risk factors.
(2) Anti-hypertensive treatment should be agreed by the medical assessor of the licensing authority. Acceptable medication may include:
(i) non-loop diuretic agents;
(ii) ACE inhibitors;
(iii) angiotensin II receptor blocking agents (sartans);
(iv) channel calcium blocking agents;
(v) certain (generally hydrophilic) beta-blocking agents.
(3) Following initiation of medication for the control of blood pressure, applicants should be re-assessed to verify that satisfactory control has been achieved and the treatment is compatible with the safe exercise of the privileges of the applicable licence(s).
(k) Coronary artery disease
(1) Chest pain of uncertain cause should require full investigation. Applicants with angina pectoris should be assessed as unfit, whether or not it is alleviated by medication.
(2) In suspected asymptomatic coronary artery disease, exercise electrocardiography should be required. Further tests may be required, which should show no evidence of myocardial ischaemia or significant coronary artery stenosis.
(3) Applicants with evidence of exercise-induced myocardial ischaemia should be assessed as unfit.
(4) After an ischaemic cardiac event or revascularisation procedure, applicants should have reduced cardiovascular risk factors to an appropriate level. Medication, when used to control cardiac symptoms, is not acceptable. All applicants should be on appropriate secondary prevention treatment.
(i) A coronary angiogram obtained around the time of, or during, the ischaemic myocardial event or revasculisation procedure and a complete, detailed clinical report of the ischaemic event and of any operative procedures should be made available to the medical assessor of the licensing authority:
(A) there should be no stenosis more than 50 % in any major untreated vessel, in any vein or artery graft or at the site of an angioplasty/stent, except in a vessel subtending a myocardial infarction;
(B) the whole coronary vascular tree should be assessed as satisfactory by a cardiologist, and particular attention should be paid to multiple stenoses and/or multiple revascularisations;
(C) Applicants with an untreated stenosis greater than 30 % in the left main or proximal left anterior descending coronary artery should be assessed as unfit.
(ii) At least 6 months from the ischaemic myocardial event or revascularisation procedure, the following investigations should be completed (equivalent tests may be substituted):
(A) an exercise ECG showing neither evidence of myocardial ischaemia nor rhythm or conduction disturbance;
(B) an echocardiogram showing satisfactory left ventricular function with no important abnormality of wall motion (such as dyskinesia or akinesia) and a left ventricular ejection fraction of 50 % or more;
(C) in cases of angioplasty/stenting, a myocardial perfusion scan or stress echocardiogram, or equivalent test, which should show no evidence of reversible myocardial ischaemia. If there is any doubt about myocardial perfusion in other cases (infarction or bypass grafting) a perfusion scan, or equivalent test, should also be carried out;
(D) further investigations, such as a 24-hour ECG, may be necessary to assess the risk of any significant rhythm disturbance.
(iii) Follow-up should be annual (or more frequently, if necessary) to ensure that there is no deterioration of the cardiovascular status. It should include a review by a cardiologist, exercise ECG and cardiovascular risk assessment. Additional investigations may be required by the medical assessor of the licensing authority.
(A) After coronary artery bypass grafting, a myocardial perfusion scan, or equivalent test, should be performed if there is any indication, and in all cases within 5 years from the procedure.
(B) In all cases, coronary angiography should be considered at any time if symptoms, signs or non-invasive tests indicate myocardial ischaemia.
(iv) Successful completion of the 6-month or subsequent review will allow a fit assessment with an OML.
(l) Rhythm and conduction disturbances
(1) Applicants with significant rhythm or conduction disturbance should undergo evaluation by a cardiologist before a fit assessment with an OML, as necessary, may be considered. Appropriate follow-up should be carried out at regular intervals. Such evaluation should include:
(i) exercise ECG to the Bruce protocol or equivalent. Bruce stage 4 should be achieved and no significant abnormality of rhythm or conduction, or evidence of myocardial ischaemia should be demonstrated. Withdrawal of cardioactive medication prior to the test should normally be required;
(ii) 24-hour ambulatory ECG which should demonstrate no significant rhythm or conduction disturbance;
(iii) 2D Doppler echocardiogram which should show no significant selective chamber enlargement or significant structural or functional abnormality, and a left ventricular ejection fraction of at least 50 %.
Further evaluation may include (equivalent tests may be substituted):
(iv) 24-hour ECG recording repeated as necessary;
(v) electrophysiological study;
(vi) myocardial perfusion imaging;
(vii) cardiac magnetic resonance imaging (MRI);
(viii) coronary angiogram.
(2) Applicants with frequent or complex forms of supra ventricular or ventricular ectopic complexes require full cardiological evaluation.
(3) Where anticoagulation is needed for a rhythm disturbance, a fit assessment with an OML may be considered if the haemorrhagic risk is acceptable and the anticoagulation is stable. Anticoagulation should be considered stable if, within the last 6 months, at least 5 INR values are documented, of which at least 4 are within the INR target range. In cases of anticoagulation medication not requiring INR monitoring, a fit assessment with an OML may be considered after review by the medical assessor of the licensing authority after a stabilisation period of 3 months.
(4) Ablation
Applicants who have undergone ablation therapy should be assessed as unfit. A fit assessment may be considered following successful catheter ablation and should require an OML for at least one year, unless an electrophysiological study, undertaken at a minimum of 2 months after the ablation, demonstrates satisfactory results. For those whose long-term outcome cannot be assured by invasive or non-invasive testing, an additional period with an OML and/or observation may be necessary.
(5) Supraventricular arrhythmias
Applicants with significant disturbance of supraventricular rhythm, including sinoatrial dysfunction, whether intermittent or established, should be assessed as unfit. A fit assessment may be considered if cardiological evaluation is satisfactory.
(i) Atrial fibrillation/flutter
(A) For initial applicants, a fit assessment should be limited to those with a single episode of arrhythmia which is considered by the medical assessor of the licensing authority to be unlikely to recur.
(B) For revalidation, applicants may be assessed as fit if cardiological evaluation is satisfactory and the stroke risk is sufficiently low. A fit assessment with an OML may be considered after a period of stable anticoagulation as prophylaxis, after review by the medical assessor of the licensing authority. Anticoagulation should be considered stable if, within the last 6 months, at least 5 INR values are documented, of which at least 4 are within the INR target range. In cases of anticoagulation medication not requiring INR monitoring, a fit assessment with an OML may be considered after review by the medical assessor of the licensing authority after a stabilisation period of 3 months.
(ii) Applicants with asymptomatic sinus pauses up to 2.5 seconds on resting electrocardiography may be assessed as fit if exercise electrocardiography, echocardiography and 24-hour ambulatory ECG are satisfactory.
(iii) Applicants with symptomatic sino-atrial disease should be assessed as unfit.
(6) Mobitz type 2 atrio-ventricular block
Applicants with Mobitz type 2 AV block should require full cardiological evaluation and may be assessed as fit in the absence of distal conducting tissue disease.
(7) Complete right bundle branch block
(i) Applicants with complete right bundle branch block should undergo a cardiological evaluation on first presentation. A fit assessment may be considered if there is no underlying pathology.
(ii) Applicants with bifascicular block may be assessed as fit with an OML after a satisfactory cardiological evaluation. The OML may be considered for removal if an electrophysiological study demonstrates no infra-Hissian block, or a 3-year period of satisfactory surveillance has been completed.
(8) Complete left bundle branch block
(i) A fit assessment may be considered subject to satisfactory cardiological evaluation and a 3-year period with an OML, and without an OML after 3 years of surveillance and satisfactory cardiological evaluation.
(ii) Investigation of the coronary arteries is necessary for applicants over age 40.
(9) Ventricular pre-excitation
(i) Asymptomatic initial applicants with pre-excitation may be assessed as fit if an electrophysiological study, including adequate drug-induced autonomic stimulation reveals no inducible re-entry tachycardia and the existence of multiple pathways is excluded.
(ii) Asymptomatic applicants with pre-excitation may be assessed as fit at revalidation with limitation(s) as appropriate. Limitations may not be necessary if an electrophysiological study, including adequate drug-induced autonomic stimulation, reveals no inducible re-entry tachycardia and the existence of multiple accessory pathways is excluded.
(10) Pacemaker
Applicants with a subendocardial pacemaker should be assessed as unfit. A fit assessment with an OML may be considered at revalidation no sooner than 3 months after insertion provided:
(i) there is no other disqualifying condition;
(ii) a bipolar lead system, programmed in bipolar mode without automatic mode change has been used;
(iii) the applicant is not pacemaker dependent; and
(iv) the applicant has a follow-up at least every 12 months, including a pacemaker check.
(11) QT prolongation
Applicants with asymptomatic QT prolongation may be assessed as fit with an OML subject to satisfactory cardiological evaluation.
(12) Brugada pattern on electrocardiography
Applicants with a Brugada pattern Type 1 should be assessed as unfit. Applicants with Type 2 or Type 3 may be assessed as fit, with limitations as appropriate, subject to satisfactory cardiological evaluation.
AMC2 MED.B.010 Cardiovascular system
ED Decision 2019/002/R
(a) Examination
Exercise electrocardiography
An exercise ECG when required as part of a cardiovascular assessment should be symptom-limited and completed to a minimum of Bruce Stage IV or equivalent.
(b) General
(1) Cardiovascular risk factor assessment
Applicants with an accumulation of risk factors (smoking, family history, lipid abnormalities, hypertension, etc.) should undergo a cardiovascular evaluation by the AeMC or AME.
(2) Cardiovascular assessment
Reporting of resting and exercise electrocardiograms should be by the AME or an accredited specialist.
(c) Peripheral arterial disease
A fit assessment may be considered for an applicant with peripheral arterial disease, or after surgery for peripheral arterial disease, provided there is no significant functional impairment, any vascular risk factors have been reduced to an appropriate level, the applicant is receiving acceptable secondary prevention treatment, and there is no evidence of myocardial ischaemia.
(d) Aortic aneurysm
(1) Applicants with an aneurysm of the infra-renal abdominal aorta of less than 5 cm in diameter may be assessed as fit, subject to satisfactory cardiological evaluation. Regular cardiological evaluations should be carried out.
(2) Applicants with an aneurysm of the thoracic or supra-renal abdominal aorta of less than 5 cm in diameter may be assessed as fit with an ORL or OSL, subject to satisfactory cardiological evaluation. Regular follow-up should be carried out.
(3) Applicants may be assessed as fit after surgery for an infra-renal abdominal aortic aneurysm, subject to satisfactory cardiological evaluation. Regular cardiological evaluations should be carried out.
(4) Applicants may be assessed as fit with an ORL or OSL after surgery for a thoracic or supra-renal abdominal aortic aneurysm, subject to satisfactory cardiological evaluation. Regular cardiological evaluations should be carried out.
(e) Cardiac valvular abnormalities
(1) Applicants with previously unrecognised cardiac murmurs should undergo further cardiological evaluation.
(2) Applicants with minor cardiac valvular abnormalities may be assessed as fit.
(3) Aortic valve disease
(i) Applicants with a bicuspid aortic valve may be assessed as fit if no other cardiac or aortic abnormality is demonstrated. Follow-up with echocardiography, as necessary, should be determined in consultation with the medical assessor of the licensing authority.
(ii) Applicants with aortic stenosis may be assessed as fit provided the left ventricular function is intact and the mean pressure gradient is less than 20 mmHg. Applicants with an aortic valve orifice of more than 1 cm2 and a mean pressure gradient above 20 mmHg, but not greater than 50 mmHg, may be assessed as fit with an ORL or OSL. Follow-up with 2D Doppler echocardiography, as necessary, should be determined in consultation with the medical assessor of the licensing authority in all cases. Alternative measurement techniques with equivalent ranges may be used. Regular cardiological evaluation should be considered. Applicants with a history of systemic embolism or significant dilatation of the thoracic aorta should be assessed as unfit.
(iii) Applicants with trivial aortic regurgitation may be assessed as fit. Applicants with a greater degree of aortic regurgitation may be assessed as fit with an OSL. There should be no demonstrable abnormality of the ascending aorta on 2D Doppler echocardiography. Follow-up, as necessary, should be determined in consultation with the medical assessor of the licensing authority.
(4) Mitral valve disease
(i) Asymptomatic applicants with an isolated mid-systolic click due to mitral leaflet prolapse may be assessed as fit.
(ii) Applicants with rheumatic mitral stenosis should be assessed as unfit.
(iii) Applicants with minor regurgitation may be assessed as fit. Periodic cardiological review should be determined in consultation with the medical assessor of the licensing authority.
(iv) Applicants with moderate mitral regurgitation may be considered as fit with an ORL or OSL if the 2D Doppler echocardiogram demonstrates satisfactory left ventricular dimensions and satisfactory myocardial function is confirmed by exercise electrocardiography. Periodic cardiological review should be determined in consultation with the medical assessor of the licensing authority.
(v) Applicants with evidence of volume overloading of the left ventricle demonstrated by increased left ventricular end-diastolic diameter or evidence of systolic impairment should be assessed as unfit.
(f) Valvular surgery
(1) Applicants who have undergone cardiac valve replacement or repair may be assessed as fit without limitations subject to satisfactory post-operative cardiological evaluation and if no anticoagulants are needed.
(2) Where anticoagulation is needed after valvular surgery, a fit assessment with an ORL or OSL may be considered after cardiological evaluation if the haemorrhagic risk is acceptable. The review should show that the anticoagulation is stable. Anticoagulation should be considered stable if, within the last 6 months, at least 5 INR values are documented, of which at least 4 are within the INR target range. The INR target range should be determined by the type of surgery performed. Applicants who measure their INR on a ‘near patient’ testing system within 12 hours prior to flight and only exercise the privileges of their licence(s) if the INR is within the target range, may be assessed as fit without the above-mentioned limitation. The INR results should be recorded and the results should be reviewed at each aero-medical assessment. Applicants taking anticoagulation medication not requiring INR monitoring, may be assessed as fit without the above-mentioned limitation in consultation with the medical assessor of the licensing authority after a stabilisation period of 3 months.
(g) Thromboembolic disorders
Applicants with arterial or venous thrombosis or pulmonary embolism should be assessed as unfit. A fit assessment with an ORL or OSL may be considered after a period of stable anticoagulation as prophylaxis in consultation with the medical assessor of the licensing authority. Anticoagulation should be considered stable if, within the last 6 months, at least 5 INR values are documented, of which at least 4 are within the INR target range and the haemorrhagic risk is acceptable. Applicants who measure their INR on a ‘near patient’ testing system within 12 hours prior to flight and only exercise the privileges of their licence(s) if the INR is within the target range may be assessed as fit without the above-mentioned limitation. The INR results should be recorded and the results should be reviewed at each aero-medical assessment. Applicants taking anticoagulation medication not requiring INR monitoring, may be assessed as fit without the above-mentioned limitation in consultation with the medical assessor of the licensing authority after a stabilisation period of 3 months. Applicants with pulmonary embolism should also undergo a cardiological evaluation. Following cessation of anticoagulant therapy for any indication, applicants should undergo a re-assessment in consultation with the medical assessor of the licensing authority.
(h) Other cardiac disorders
(1) Applicants with a primary or secondary abnormality of the pericardium, myocardium or endocardium may be assessed as fit subject to satisfactory cardiological evaluation.
(2) Applicants with a congenital abnormality of the heart, including those who have undergone surgical correction, may be assessed as fit subject to satisfactory cardiological evaluation. Cardiological follow-up may be necessary and should be determined in consultation with the medical assessor of the licensing authority.
(i) Syncope
(1) In the case of a single episode of vasovagal syncope which can be explained and is compatible with flight safety, a fit assessment may be considered.
(2) Applicants with a history of recurrent vasovagal syncope should be assessed as unfit. A fit assessment may be considered after a 6-month period without recurrence, providing cardiological evaluation is satisfactory. Neurological review may be indicated.
(j) Blood pressure
(1) When the blood pressure at examination consistently exceeds 160 mmHg systolic and/or 95 mmHg diastolic, with or without treatment, the applicant should be assessed as unfit.
(2) The diagnosis of hypertension requires review of other potential vascular risk factors.
(3) Applicants with symptomatic hypotension should be assessed as unfit.
(4) Anti-hypertensive treatment should be compatible with flight safety.
(5) Following initiation of medication for the control of blood pressure, applicants should be re-assessed to verify that satisfactory control has been achieved and that the treatment is compatible with the safe exercise of the privileges of the applicable licence(s).
(k) Coronary artery disease
(1) Chest pain of uncertain cause requires full investigation.
(2) Applicants with suspected asymptomatic coronary artery disease should undergo cardiological evaluation which should show no evidence of myocardial ischaemia or significant coronary artery stenosis.
(3) Applicants with evidence of exercise-induced myocardial ischaemia should be assessed as unfit.
(4) After an ischaemic cardiac event, or revascularisation, applicants without symptoms should have reduced cardiovascular risk factors to an appropriate level. Medication, when used to control angina pectoris, is not acceptable. All applicants should be on appropriate secondary prevention treatment.
(i) A coronary angiogram obtained around the time of, or during, the ischaemic myocardial event and a complete, detailed clinical report of the ischaemic event and of any operative procedures should be available to the AME.
(A) There should be no stenosis more than 50 % in any major untreated vessel, in any vein or artery graft or at the site of an angioplasty/stent, except in a vessel subtending a myocardial infarction.
(B) The whole coronary vascular tree should be assessed as satisfactory by a cardiologist and particular attention should be paid to multiple stenoses and/or multiple revascularisations.
(C) Applicants with an untreated stenosis greater than 30 % in the left main or proximal left anterior descending coronary artery should be assessed as unfit.
(ii) At least 6 months from the ischaemic myocardial event, including revascularisation, the following investigations should be completed (equivalent tests may be substituted):
(A) an exercise ECG showing neither evidence of myocardial ischaemia nor rhythm disturbance;
(B) an echocardiogram showing satisfactory left ventricular function with no important abnormality of wall motion and a satisfactory left ventricular ejection fraction of 50 % or more;
(C) in cases of angioplasty/stenting, a myocardial perfusion scan or stress echocardiogram, or equivalent test, which should show no evidence of reversible myocardial ischaemia. If there is doubt about revascularisation in myocardial infarction or bypass grafting, a perfusion scan, or equivalent test, should also be carried out;
(D) further investigations, such as a 24-hour ECG, may be necessary to assess the risk of any significant rhythm disturbance.
(iii) Periodic follow-up should include a cardiological evaluation.
(A) After coronary artery bypass grafting, a myocardial perfusion scan (or equivalent test) should be performed if there is any indication, and in all cases within five years from the procedure for a fit assessment without an OSL, OPL or ORL.
(B) In all cases, coronary angiography should be considered at any time if symptoms, signs or non-invasive tests indicate myocardial ischaemia.
(iv) Successful completion of the six-month or subsequent review will allow a fit assessment. Applicants may be assessed as fit with an ORL or OSL having successfully completed only an exercise ECG.
(5) Applicants with angina pectoris should be assessed as unfit, whether or not it is alleviated by medication.
(l) Rhythm and conduction disturbances
(1) Applicants with significant rhythm or conduction disturbance should undergo cardiological evaluation before a fit assessment may be considered with an ORL or OSL, as appropriate. Such evaluation should include:
(i) exercise ECG to the Bruce protocol or equivalent. Bruce stage 4 should be achieved and no significant abnormality of rhythm or conduction, or evidence of myocardial ischaemia should be demonstrated. Withdrawal of cardioactive medication prior to the test should normally be required;
(ii) 24-hour ambulatory ECG which should demonstrate no significant rhythm or conduction disturbance;
(iii) 2D Doppler echocardiogram which should show no significant selective chamber enlargement or significant structural or functional abnormality, and a left ventricular ejection fraction of at least 50 %.
Further evaluation may include (equivalent tests may be substituted):
(iv) 24-hour ECG recording repeated as necessary;
(v) electrophysiological study;
(vi) myocardial perfusion imaging;
(vii) cardiac magnetic resonance imaging (MRI);
(viii) coronary angiogram.
(2) Where anticoagulation is needed for a rhythm disturbance, a fit assessment with an ORL or OSL may be considered, if the haemorrhagic risk is acceptable and the anticoagulation is stable. Anticoagulation should be considered stable if, within the last 6 months, at least 5 INR values are documented, of which at least 4 are within the INR target range. Applicants who measure their INR on a ‘near patient’ testing system within 12 hours prior to flight and only exercise the privileges of their licence(s) if the INR is within the target range may be assessed as fit without the above-mentioned limitation. The INR results should be recorded and the results should be reviewed at each aero-medical assessment. Applicants taking anticoagulation medication not requiring INR monitoring, may be assessed as fit without the above-mentioned limitation in consultation with the medical assessor of the licensing authority after a stabilisation period of 3 months.
(3) Ablation
A fit assessment may be considered following successful catheter ablation subject to satisfactory cardiological review undertaken at a minimum of 2 months after the ablation.
(4) Supraventricular arrhythmias
(i) Applicants with significant disturbance of supraventricular rhythm, including sinoatrial dysfunction, whether intermittent or established, may be assessed as fit if cardiological evaluation is satisfactory.
(ii) Applicants with atrial fibrillation/flutter may be assessed as fit if cardiological evaluation is satisfactory and the stroke risk is sufficiently low. Where anticoagulation is needed, a fit assessment with an ORL or OSL may be considered after a period of stable anticoagulation as prophylaxis, in consultation with the medical assessor of the licensing authority. Anticoagulation should be considered stable if, within the last 6 months, at least 5 INR values are documented, of which at least 4 are within the INR target range. Applicants who measure their INR on a ‘near patient’ testing system within 12 hours prior to flight and only exercise the privileges of their licence(s) if the INR is within the target range may be assessed as fit without the above-mentioned limitation. The INR results should be recorded and the results should be reviewed at each aero-medical assessment. Applicants taking anticoagulation medication not requiring INR monitoring, may be assessed as fit without the above-mentioned limitation in consultation with the medical assessor of the licensing authority after a stabilisation period of 3 months.
(iii) Applicants with asymptomatic sinus pauses up to 2.5 seconds on resting electrocardiography may be assessed as fit if cardiological evaluation is satisfactory.
(5) Heart block
(i) Applicants with first degree and Mobitz type 1 AV block may be assessed as fit.
(ii) Applicants with Mobitz type 2 AV block may be assessed as fit in the absence of distal conducting tissue disease.
(6) Complete right bundle branch block
Applicants with complete right bundle branch block may be assessed as fit with appropriate limitations, such as an ORL, and subject to satisfactory cardiological evaluation.
(7) Complete left bundle branch block
Applicants with complete left bundle branch block may be assessed as fit with appropriate limitations, such as an ORL, and subject to satisfactory cardiological evaluation.
(8) Ventricular pre-excitation
Asymptomatic applicants with ventricular pre-excitation may be assessed as fit with limitation(s) as appropriate, subject to satisfactory cardiological evaluation. Limitations may not be necessary if an electrophysiological study is conducted and the results are satisfactory.
(9) Pacemaker
Applicants with a subendocardial pacemaker should be assessed as unfit. A fit assessment may be considered no sooner than 3 months after insertion, providing:
(i) there is no other disqualifying condition;
(ii) a bipolar lead system, programmed in bipolar mode without automatic mode change, has been used;
(iii) the applicant is not pacemaker dependent; and
(iv) the applicant has a follow-up at least every 12 months, including a pacemaker check.
(10) QT prolongation
Applicants with asymptomatic QT prolongation may be assessed as fit with an ORL or OSL subject to satisfactory cardiological evaluation.
(11) Brugada pattern on electrocardiography
Applicants with a Brugada pattern Type 1 should be assessed as unfit. Applicants with Type 2 or Type 3 may be assessed as fit, with limitation(s) as appropriate, subject to satisfactory cardiological evaluation.
(m) Heart or heart/lung transplantation
(1) Applicants who have undergone heart or heart/lung transplantation may be assessed as fit, with appropriate limitation(s) such as an ORL , no sooner than 12 months after transplantation, provided that cardiological evaluation is satisfactory with:
(i) no rejection in the first year following transplantation;
(ii) no significant arrhythmias;
(iii) a left ventricular ejection fraction ≥ 50%;
(iv) a symptom limited exercise ECG; and
(v) a coronary angiogram if indicated;
(2) Regular cardiological evaluations should be carried out.
GM1 MED.B.010 Cardiovascular system
ED Decision 2019/002/R
MITRAL VALVE DISEASE
(a) Minor regurgitation should have evidence of no thickened leaflets or flail chordae and left atrial internal diameter of less than or equal to 4.0 cm.
(b) The following may indicate severe regurgitation:
(1) LV internal diameter (diastole) > 6.0 cm; or
(2) LV internal diameter (systole) > 4.1 cm; or
(3) Left atrial internal diameter > 4.5 cm.
(c) Doppler indices, such as width of jet, backwards extension and whether there is flow reversal in the pulmonary veins may be helpful in assessing severity of regurgitation.
GM2 MED.B.010 Cardiovascular system
ED Decision 2019/002/R
VENTRICULAR PRE-EXCITATION
Asymptomatic applicants with pre-excitation may be assessed as fit if they meet the following criteria, which may also indicate a satisfactory electrophysiological evaluation:
(a) refractory period > 300 ms;
(b) no induced atrial fibrillation.
GM3 MED.B.010 Cardiovascular system
ED Decision 2019/002/R
ANTICOAGULATION
Applicants taking anticoagulant medication which requires monitoring with INR testing, should measure their INR on a ‘near patient’ testing system within 12 hours prior to flight and the privileges of the applicable licence(s) should only be exercised if the INR is within the target range. The INR result should be recorded and the results should be reviewed at each aero-medical assessment.
GM4 MED.B.010 Cardiovascular system
ED Decision 2019/002/R
MITRAL VALVE DISEASE
(a) Minor regurgitation should have evidence of no thickened leaflets or flail chordae and left atrial internal diameter of less than or equal to 4.0 cm.
(b) The following may indicate severe regurgitation:
(1) LV internal diameter (diastole) > 6.0 cm; or
(2) LV internal diameter (systole) > 4.1 cm; or
(3) Left atrial internal diameter > 4.5 cm.
(c) Doppler indices, such as width of jet, backwards extension and whether there is flow reversal in the pulmonary veins may be helpful in assessing severity of regurgitation.
GM5 MED.B.010 Cardiovascular system
ED Decision 2019/002/R
VENTRICULAR PRE-EXCITATION
Asymptomatic applicants with pre-excitation may be assessed as fit if they meet the following criteria:
(a) no inducible re-entry tachycardia;
(b) refractory period > 300 ms;
(c) no induced atrial fibrillation;
(d) no evidence of multiple accessory pathways.
Regulation (EU) 2019/27
(a) Applicants with significant impairment of pulmonary function shall be assessed as unfit. However, they may be assessed as fit once pulmonary function has recovered and is satisfactory.
(b) Applicants for a class 1 medical certificate shall undertake pulmonary morphological and functional tests at the initial examination and when clinically indicated.
(c) Applicants for a class 2 medical certificate shall undertake pulmonary morphological and functional tests when clinically indicated.
(d) Applicants with a medical history or diagnosis of any of the following medical conditions shall undertake respiratory evaluation with a satisfactory result before they may be assessed as fit:
(1) asthma requiring medication;
(2) active inflammatory disease of the respiratory system;
(3) active sarcoidosis;
(4) pneumothorax;
(5) sleep apnoea syndrome;
(6) major thoracic surgery;
(7) pneumonectomy;
(8) chronic obstructive pulmonary disease.
Before further consideration is given to their application, applicants with an established diagnosis of any of the medical conditions specified in points (3) and (5) shall undergo satisfactory cardiological evaluation.
(e) Aero-medical assessment
(1) Applicants for a class 1 medical certificate with any of the medical conditions specified in point (d) shall be referred to the medical assessor of the licensing authority.
(2) Applicants for a class 2 medical certificate with any of the medical conditions specified in point (d) shall be assessed in consultation with the medical assessor of the licensing authority.
(f) Applicants for a class 1 medical certificate who have undergone a pneumonectomy shall be assessed as unfit.
AMC1 MED.B.015 Respiratory system
ED Decision 2019/002/R
(a) Examination
(1) Spirometry
A spirometric examination is required for initial examination and on clinical indication. Applicants with an FEV1/FVC ratio of less than 70 % should be evaluated by a specialist in respiratory disease.
(2) Chest radiography
Posterior/anterior chest radiography may be required at initial, revalidation or renewal examinations if clinically or epidemiologically indicated
(b) Chronic obstructive pulmonary disease
Applicants with chronic obstructive pulmonary disease should be assessed as unfit. Applicants with only minor impairment of pulmonary function may be assessed as fit.
(c) Asthma
Applicants with asthma requiring medication or experiencing recurrent attacks of asthma may be assessed as fit if the asthma is considered stable with satisfactory pulmonary function tests and medication is compatible with flight safety. Applicants requiring systemic steroids should be assessed as unfit.
(d) Inflammatory disease
For applicants with active inflammatory disease of the respiratory system a fit assessment may be considered when the condition has resolved without sequelae and no medication is required.
(e) Sarcoidosis
(1) Applicants with active sarcoidosis should be assessed as unfit. Investigation should be undertaken with respect to the possibility of systemic, particularly cardiac, involvement. A fit assessment may be considered if no medication is required, and the disease is investigated and shown to be limited to hilar lymphadenopathy and inactive.
(2) Applicants with cardiac or neurological sarcoid should be assessed as unfit.
(f) Pneumothorax
(1) Applicants with a spontaneous pneumothorax should be assessed as unfit. A fit assessment may be considered if respiratory evaluation is satisfactory:
(i) 1 year following full recovery from a single spontaneous pneumothorax;
(ii) at revalidation, 6 weeks following full recovery from a single spontaneous pneumothorax, with an OML for at least a year after full recovery;
(iii) following surgical intervention in the case of a recurrent pneumothorax provided there is satisfactory recovery.
(2) Applicants with a recurrent spontaneous pneumothorax that has not been surgically should be assessed as unfit.
(3) A fit assessment following full recovery from a traumatic pneumothorax as a result of an accident or injury may be acceptable once full absorption of the pneumothorax is demonstrated.
(g) Thoracic surgery
(1) Applicants requiring major thoracic surgery should be assessed as unfit until recovery is complete, the applicant is asymptomatic, and the risk of secondary complication is minimal.
(2) A fit assessment following lesser chest surgery may be considered after satisfactory recovery and full respiratory evaluation.
(h) Sleep apnoea syndrome/sleep disorder
Applicants with unsatisfactorily treated sleep apnoea syndrome should be assessed as unfit.
AMC2 MED.B.015 Respiratory system
ED Decision 2019/002/R
(a) Examination
(1) A spirometric examination should be performed on clinical indication. Applicants with a forced expiratory volume in the first one second (FEV1)/forced vital capacity(FVC)ratio of less than 70 % should be evaluated by a specialist in respiratory disease.
(2) Posterior/anterior chest radiography may be required if clinically or epidemiologically indicated.
(b) Chronic obstructive pulmonary disease
Applicants with only minor impairment of pulmonary function may be assessed as fit.
(c) Asthma
Applicants with asthma may be assessed as fit if the asthma is considered stable with satisfactory pulmonary function tests and medication is compatible with flight safety. Applicants requiring systemic steroids should be assessed as unfit.
(d) Inflammatory disease
Applicants with active inflammatory disease of the respiratory system should be assessed as unfit pending resolution of the condition.
(e) Sarcoidosis
(1) Applicants with active sarcoidosis should be assessed as unfit. Investigation should be undertaken with respect to the possibility of systemic involvement. A fit assessment may be considered once the disease is inactive.
(2) Applicants with cardiac sarcoid should be assessed as unfit.
(f) Pneumothorax
(1) Applicants with spontaneous pneumothorax should be assessed as unfit. A fit assessment may be considered if respiratory evaluation is satisfactory:
(i) six weeks following full recovery from a single spontaneous pneumothorax;
(ii) following surgical intervention in the case of a recurrent pneumothorax, provided there is satisfactory recovery.
(2) A fit assessment following full recovery from a traumatic pneumothorax as a result of an accident or injury may be acceptable once full absorption of the pneumothorax is demonstrated.
(g) Thoracic surgery
Applicants requiring major thoracic surgery should be assessed as unfit until recovery is complete, the applicant is asymptomatic, and the risk of secondary complication is minimal.
(h) Sleep apnoea syndrome
Applicants with unsatisfactorily treated sleep apnoea syndrome should be assessed as unfit.
Regulation (EU) 2019/27
(a) Applicants with any sequelae of disease or surgical intervention in any part of the digestive tract or its adnexa likely to cause incapacitation in flight, in particular any obstruction due to stricture or compression, shall be assessed as unfit.
(b) Applicants who have herniae that might give rise to incapacitating symptoms shall be assessed as unfit.
(c) Applicants with any of the following disorders of the gastrointestinal system may be assessed as fit subject to satisfactory gastrointestinal evaluation after successful treatment or full recovery after surgery:
(1) recurrent dyspeptic disorder requiring medication;
(2) pancreatitis;
(3) symptomatic gallstones;
(4) a clinical diagnosis or documented medical history of chronic inflammatory bowel disease;
(5) after surgical operation on the digestive tract or its adnexa, including surgery involving total or partial excision or a diversion of any of these organs.
(d) Aero-medical assessment
(1) Applicants for a class 1 medical certificate with the diagnosis of any of the medical conditions specified in points (2), (4) and (5) of point (c) shall be referred to the medical assessor of the licensing authority.
(2) The fitness of applicants for a class 2 medical certificate with the diagnosis of the medical condition specified in point (2) of point (c) shall be assessed in consultation with the medical assessor of the licensing authority.
AMC1 MED.B.020 Digestive system
ED Decision 2019/002/R
(a) Oesophageal varices
Applicants with oesophageal varices should be assessed as unfit.
(b) Pancreatitis
Applicants with pancreatitis should be assessed as unfit pending assessment. A fit assessment may be considered if the cause is removed.
(c) Gallstones
(1) Applicants with a single asymptomatic large gallstone discovered incidentally may be assessed as fit if not likely to cause incapacitation in flight.
(2) Applicants with asymptomatic multiple gallstones may be assessed as fit with an OML.
(d) Inflammatory bowel disease
Applicants with an established diagnosis or history of chronic inflammatory bowel disease should be assessed as fit if the inflammatory bowel disease is in established remission and stable and if systemic steroids are not required for its control.
(e) Peptic ulceration
Applicants with peptic ulceration should be assessed as unfit pending full recovery and demonstrated healing.
(f) Digestive tract and abdominal surgery
Applicants who have undergone a surgical operation for medical conditions of the digestive tract or its adnexa, including a total or partial excision or a diversion of any of these organs or herniae should be assessed as unfit. A fit assessment may be considered if recovery is complete, the applicant is asymptomatic, and there is only a minimal risk of secondary complication or recurrence.
(g) Liver disease
Applicants with morphological or functional liver disease, or after surgery, including liver transplantation, may be assessed as fit subject to satisfactory gastroenterological evaluation.
AMC2 MED.B.020 Digestive system
ED Decision 2019/002/R
(a) Oesophageal varices
Applicants with oesophageal varices should be assessed as unfit.
(b) Pancreatitis
Applicants with pancreatitis should be assessed as unfit pending satisfactory recovery.
(c) Gallstones
(1) Applicants with a single asymptomatic large gallstone or asymptomatic multiple gallstones may be assessed as fit.
(2) Applicants with symptomatic single or multiple gallstones should be assessed as unfit. A fit assessment may be considered following gallstone removal.
(d) Inflammatory bowel disease
Applicants with an established diagnosis or history of chronic inflammatory bowel disease may be assessed as fit provided that the disease is stable and not likely to interfere with the safe exercise of the privileges of the applicable licence(s).
(e) Peptic ulceration
Applicants with peptic ulceration should be assessed as unfit pending full recovery.
(f) Digestive tract and abdominal surgery
Applicants who have undergone a surgical operation:
(1) for herniae; or
(2) on the digestive tract or its adnexa, including a total or partial excision or diversion of any of these organs
should be assessed as unfit. A fit assessment may be considered if recovery is complete, the applicant is asymptomatic, and there is only a minimal risk of secondary complication or recurrence.
(g) Liver disease
Applicants with morphological or functional liver disease, or after surgery, including liver transplantation, may be assessed as fit subject to satisfactory gastroenterological evaluation.
MED.B.025 Metabolic and Endocrine Systems
Regulation (EU) 2019/27
(a) Applicants with metabolic, nutritional or endocrine dysfunction may be assessed as fit subject to demonstrated stability of the medical condition and satisfactory aero-medical evaluation.
(b) Diabetes mellitus
(1) Applicants with diabetes mellitus requiring insulin shall be assessed as unfit.
(2) Applicants with diabetes mellitus not requiring insulin shall be assessed as unfit unless it can be demonstrated that blood sugar control has been achieved and is stable.
(c) Aero-medical assessment
(1) Applicants for a class 1 medical certificate requiring medication other than insulin for blood sugar control shall be referred to the medical assessor of the licensing authority.
(2) The fitness of applicants for a class 2 medical certificate requiring medication other than insulin for blood sugar control shall be assessed in consultation with the medical assessor of the licensing authority.
AMC1 MED.B.025 Metabolic and endocrine systems
ED Decision 2019/002/R
(a) Metabolic, nutritional or endocrine dysfunction
Applicants with metabolic, nutritional or endocrine dysfunction may be assessed as fit if the condition is asymptomatic, clinically compensated and stable with or without replacement therapy, and regularly reviewed by an appropriate specialist.
(b) Obesity
Applicants with a Body Mass Index 35 may be assessed as fit only if the excess weight is not likely to interfere with the safe exercise of the applicable licence(s) and the results of a risk assessment, including evaluation of the cardiovascular system and evaluation of the possibility of sleep apnoea, are satisfactory.
(c) Addison’s disease
Applicants with Addison’s disease should be assessed as unfit. A fit assessment with an OML may be considered, provided that cortisone is carried and available for use whilst exercising the privileges of the applicable licence(s).
(d) Gout
Applicants with acute gout should be assessed as unfit. A fit assessment may be considered once asymptomatic, after cessation of treatment or the condition is stabilised on anti-hyperuricaemic therapy.
(e) Thyroid dysfunction
Applicants with hyperthyroidism or hypothyroidism should be assessed as unfit. A fit assessment may be considered when a stable euthyroid state is attained.
(f) Abnormal glucose metabolism
Glycosuria and abnormal blood glucose levels require investigation. A fit assessment may be considered if normal glucose tolerance is demonstrated (low renal threshold) or impaired glucose tolerance without diabetic pathology is fully controlled by diet and regularly reviewed.
(g) Diabetes mellitus
Subject to good control of blood sugar with no hypoglycaemic episodes:
(1) applicants with diabetes mellitus not requiring medication may be assessed as fit;
(2) the use of antidiabetic medications that are not likely to cause hypoglycaemia may be acceptable for a fit assessment with an OML.
AMC2 MED.B.025 Metabolic and endocrine systems
ED Decision 2019/002/R
(a) Metabolic, nutritional or endocrine dysfunction
Applicants with metabolic, nutritional or endocrine dysfunction should be assessed as unfit. A fit assessment may be considered if the condition is asymptomatic, clinically compensated and stable.
(b) Obesity
Applicants with a Body Mass Index 35 may be assessed as fit only if the excess weight is not likely to interfere with the safe exercise of the applicable licence(s) and the results of a risk assessment, including evaluation of the cardiovascular system and evaluation of the possibility of sleep apnoea, are satisfactory.
(c) Addison’s disease
Applicants with Addison’s disease may be assessed as fit provided that cortisone is carried and available for use whilst exercising the privileges of the applicable licence(s).
(d) Gout
Applicants with acute gout should be assessed as unfit until asymptomatic.
(e) Thyroid dysfunction
Applicants with thyroid disease may be assessed as fit once a stable euthyroid state is attained.
(f) Abnormal glucose metabolism
Glycosuria and abnormal blood glucose levels require investigation. A fit assessment may be considered if normal glucose tolerance is demonstrated (low renal threshold) or impaired glucose tolerance is fully controlled by diet and regularly reviewed.
(g) Diabetes mellitus
Applicants with diabetes mellitus may be assessed as fit. The use of antidiabetic medications that are not likely to cause hypoglycaemia may be acceptable.
Regulation (EU) 2019/27
(a) Applicants for a class 1 medical certificate shall be subjected to an haemoglobin test at each aero-medical examination.
(b) Applicants with a haematological condition may be assessed as fit subject to satisfactory aero-medical evaluation.
(c) Applicants for a class 1 medical certificate with any of the following haematological conditions shall be referred to the medical assessor of the licensing authority:
(1) abnormal haemoglobin, including, but not limited to anaemia, erythrocytosis or haemoglobinopathy;
(2) significant lymphatic enlargement;
(3) enlargement of the spleen;
(4) coagulation, haemorrhagic or thrombotic disorder;
(5) leukaemia.
(d) The fitness of applicants for a class 2 medical certificate with any of the haematological conditions specified in points (4) and (5) of point (c) shall be assessed in consultation with the medical assessor of the licensing authority.
ED Decision 2019/002/R
(a) Abnormal haemoglobin
Applicants with abnormal haemoglobin should be investigated.
(b) Anaemia
(1) Applicants with anaemia demonstrated by a reduced haemoglobin level require investigation. Applicants with an haematocrit of less than 32 % should be assessed as unfit. A fit assessment may be considered in cases where the primary cause, such as iron or B12 deficiency, has been treated and the haemoglobin or haematocrit has stabilised at a satisfactory level.
(2) Applicants with anaemia which is unamenable to treatment should be assessed as unfit.
(c) Erythrocytosis
Applicants with erythrocytosis should be assessed as unfit. A fit assessment with an OML may be considered if investigation establishes that the condition is stable and no associated pathology is demonstrated.
(d) Haemoglobinopathy
(1) Applicants with a haemoglobinopathy should be assessed as unfit. A fit assessment may be considered where minor thalassaemia or other haemoglobinopathy is diagnosed without a history of crises and where full functional capability is demonstrated. The haemoglobin level should be satisfactory.
(2) Applicants with sickle cell disease (homozygote) should be assessed as unfit.
(e) Coagulation disorders
(1) Applicants with a coagulation disorder should be assessed as unfit. A fit assessment may be considered if there is no history of significant bleeding episodes.
(2) Applicants with thrombocytopenia with a platelet count less than 75x109/L should be assessed as unfit. A fit assessment may be considered once the platelet count is above 75x109/L and stable.
(f) Haemorrhagic disorders
Applicants with a haemorrhagic disorder require investigation. A fit assessment with an OML may be considered if there is no history of significant bleeding.
(g) Thromboembolic disorders
(1) Applicants with a thrombotic disorder require investigation. A fit assessment may be considered when the applicant is asymptomatic and there is only minimal risk of secondary complication or recurrence.
(2) If anticoagulation is used as treatment, refer to AMC1 MED.B.010(g).
(3) Applicants with arterial embolus should be assessed as unfit. A fit assessment may be considered once recovery is complete, the applicant is asymptomatic, and there is only minimal risk of secondary complication or recurrence.
(h) Disorders of the lymphatic system
Applicants with significant localised and generalised enlargement of the lymphatic glands or haematological disease should be assessed as unfit and require investigation. A fit assessment may be considered in cases of an acute infectious process which is fully recovered or Hodgkin’s lymphoma or other lymphoid malignancy which has been treated and is in full remission.
(i) Leukaemia
(1) Applicants with acute leukaemia should be assessed as unfit. Once in established remission, applicants may be assessed as fit.
(2) Applicants with chronic leukaemia should be assessed as unfit. After a period of demonstrated stability a fit assessment may be considered.
(3) Applicants with a history of leukaemia should have no history of central nervous system involvement and no continuing side-effects from treatment of flight safety importance. Haemoglobin and platelet levels should be satisfactory. Regular follow-up is required.
(j) Splenomegaly
Applicants with splenomegaly should be assessed as unfit and require investigation. A fit assessment may be considered when the enlargement is minimal, stable and no associated pathology is demonstrated, or if the enlargement is minimal and associated with another acceptable condition.
ED Decision 2019/002/R
(a) Abnormal haemoglobin
Haemoglobin should be tested when clinically indicated.
(b) Anaemia
Applicants with anaemia demonstrated by a reduced haemoglobin level or low haematocrit may be assessed as fit once the primary cause has been treated and the haemoglobin or haematocrit has stabilised at a satisfactory level.
(c) Erythrocytosis
Applicants with erythrocytosis may be assessed as fit if the condition is stable and no associated pathology is demonstrated.
(d) Haemoglobinopathy
Applicants with a haemoglobinopathy may be assessed as fit if minor thalassaemia or other haemoglobinopathy is diagnosed without a history of crises and where full functional capability is demonstrated.
(e) Coagulation and haemorrhagic disorders
Applicants with a coagulation or haemorrhagic disorder may be assessed as fit if there is no likelihood of significant bleeding.
(f) Thromboembolic disorders
Applicants with a thrombotic disorder may be assessed as fit if there is minimal likelihood of significant clotting episodes. If anticoagulation is used as treatment, refer to AMC2 MED.B.010(g).
(g) Disorders of the lymphatic system
Applicants with significant enlargement of the lymphatic glands or haematological disease may be assessed as fit if the condition is unlikely to interfere with the safe exercise of the privileges of the applicable licence(s). Applicants may be assessed as fit in cases of acute infectious process which is fully recovered or Hodgkin's lymphoma or other lymphoid malignancy which has been treated and is in full remission.
(h) Leukaemia
(1) Applicants with acute leukaemia may be assessed as fit once in established remission.
(2) Applicants with chronic leukaemia may be assessed as fit after a period of demonstrated stability.
(3) In cases (h)(1) and (h)(2), there should be no history of central nervous system involvement and no continuing side effects from treatment of flight safety importance. Haemoglobin and platelet levels should be satisfactory. Regular follow-up is required.
(i) Splenomegaly
Applicants with splenomegaly may be assessed as fit if the enlargement is minimal, stable and no associated pathology is demonstrated, or if the enlargement is minimal and associated with another acceptable condition.
MED.B.035 Genitourinary System
Regulation (EU) 2019/27
(a) Urinalysis shall form part of each aero-medical examination. Applicants shall be assessed as unfit where their urine contains abnormal elements considered to be of pathological significance that could entail a degree of functional incapacity which is likely to jeopardise the safe exercise of the privileges of the license or could render the applicant likely to become suddenly unable to exercise those privileges.
(b) Applicants with any sequelae of disease or surgical procedures on the genitourinary system or its adnexa likely to cause incapacitation, in particular any obstruction due to stricture or compression, shall be assessed as unfit.
(c) Applicants with a diagnosis or medical history of the following may be assessed as fit subject to satisfactory genitourinary evaluation, as applicable:
(1) renal disease;
(2) one or more urinary calculi, or a medical history of renal colic.
(d) Applicants who have undergone a major surgical operation in the genitourinary system or its adnexa involving a total or partial excision or a diversion of their organs shall be assessed as unfit. However, after full recovery, they may be assessed as fit.
(e) The applicants for a class 1 medical certificate referred to in points (c) and (d) shall be referred to the medical assessor of the licensing authority.
AMC1 MED.B.035 Genitourinary system
ED Decision 2019/002/R
(a) Abnormal urinalysis
Investigation is required if there is any abnormal finding on urinalysis.
(b) Renal disease
(1) Applicants presenting with any signs of renal disease should be assessed as unfit. A fit assessment may be considered if blood pressure is satisfactory and renal function is acceptable.
(2) Applicants requiring dialysis should be assessed as unfit.
(c) Urinary calculi
(1) Applicants with an asymptomatic calculus or a history of renal colic require investigation.
(2) Applicants presenting with one or more urinary calculi should be assessed as unfit and require investigation.
(3) Whilst awaiting assessment or treatment, a fit assessment with an OML may be considered.
(4) After successful treatment for a calculus a fit assessment without an OML may be considered.
(5) Applicants with parenchymal residual calculi may be considered for a fit assessment with an OML.
(d) Renal and urological surgery
(1) Applicants who have undergone a major surgical operation on the genitourinary system or its adnexa involving a total or partial excision or a diversion of any of its organs, should be assessed as unfit until recovery is complete, the applicant is asymptomatic, and the risk of secondary complication is minimal.
(2) After other urological surgery, a fit assessment may be considered when the applicant is completely asymptomatic and there is only minimal risk of secondary complication or recurrence.
(3) Applicants with compensated nephrectomy without hypertension or uraemia may be considered for a fit assessment.
(4) Applicants who have undergone renal transplantation may be considered for a fit assessment with an OML if it is fully compensated and tolerated with only minimal immuno-suppressive therapy after at least 12 months.
(5) Applicants who have undergone total cystectomy may be considered for a fit assessment with an OML if there is satisfactory urinary function, no infection and no recurrence of primary pathology.
AMC2 MED.B.035 Genitourinary system
ED Decision 2019/002/R
(a) Renal disease
Applicants presenting with renal disease may be assessed as fit if blood pressure is satisfactory and renal function is acceptable. Applicants requiring dialysis should be assessed as unfit.
(b) Urinary calculi
(1) Applicants presenting with one or more urinary calculi should be assessed as unfit.
(2) Applicants with an asymptomatic calculus or a history of renal colic require investigation.
(3) While awaiting assessment or treatment, a fit assessment with an OSL may be considered.
(4) After successful treatment the applicant may be assessed as fit.
(5) Applicants with parenchymal residual calculi may be assessed as fit.
(c) Renal and urological surgery
(1) Applicants who have undergone a major surgical operation on the genitourinary system or its adnexa involving a total or partial excision or a diversion of any of its organs, should be assessed as unfit until recovery is complete, the applicant is asymptomatic, and the risk of secondary complication is minimal.
(2) After other urological surgery, a fit assessment may be considered when the applicant is completely asymptomatic and there is only minimal risk of secondary complication or recurrence.
(3) Applicants with compensated nephrectomy without hypertension or uraemia may be assessed as fit.
(4) Applicants who have undergone renal transplantation may be considered for a fit assessment if it is fully compensated and with only minimal immuno-suppressive therapy.
(5) Applicants who have undergone total cystectomy may be considered for a fit assessment if there is satisfactory urinary function, no infection and no recurrence of primary pathology.
Regulation (EU) 2019/27
(a) Applicants shall be assessed as unfit where they have a clinical diagnosis or medical history of any infectious disease which is likely to jeopardise the safe exercise of the privileges of the licence.
(b) Applicants who are HIV positive may be assessed as fit subject to satisfactory aero-medical evaluation. Such applicants for a class 1 medical certificate shall be referred to the medical assessor of the licensing authority.
AMC1 MED.B.040 Infectious disease
ED Decision 2019/002/R
(a) Infectious disease General
In cases of infectious disease, consideration should be given to a history of, or clinical signs indicating, underlying impairment of the immune system.
(b) Tuberculosis
(1) Applicants with active tuberculosis should be assessed as unfit. A fit assessment may be considered following completion of therapy.
(2) Applicants with quiescent or healed lesions may be assessed as fit. Specialist evaluation should consider the extent of the disease, the treatment required and possible side effects of medication.
(c) Syphilis
Applicants with acute syphilis should be assessed as unfit. A fit assessment may be considered in the case of those fully treated and recovered from the primary and secondary stages.
(d) HIV positivity
(1) Applicants who are HIV positive may be assessed as fit with an OML if a full investigation provides no evidence of HIV associated diseases that might give rise to incapacitating symptoms. Frequent review of the immunological status and neurological evaluation by an appropriate specialist should be carried out. A cardiological evaluation may also be required, depending on the medication.
(2) Applicants with signs or symptoms of an AIDS-defining condition should be assessed as unfit.
(e) Infectious hepatitis
Applicants with infectious hepatitis should be assessed as unfit. A fit assessment may be considered once the applicant has become asymptomatic. Regular review of the liver function should be carried out.
AMC2 MED.B.040 Infectious disease
ED Decision 2019/002/R
(a) Tuberculosis
(1) Applicants with active tuberculosis should be assessed as unfit. A fit assessment may be considered following completion of therapy.
(2) Applicants with quiescent or healed lesions may be assessed as fit. Specialist evaluation should consider the extent of the disease, the treatment required and possible side effects of medication.
(b) HIV positivity
(1) Applicants who are HIV positive may be assessed as fit if a full investigation provides no evidence of HIV associated diseases that might give rise to incapacitating symptoms. Frequent review of the immunological status and neurological evaluation by an appropriate specialist should be carried out. A cardiological evaluation may be required, depending on the medication.
(2) Applicants with signs or symptoms of an AIDS-defining condition should be assessed as unfit.
MED.B.045 Obstetrics and Gynaecology
Regulation (EU) 2019/27
(a) Applicants who have undergone a major gynaecological operation shall be assessed as unfit. However, they may be assessed as fit after full recovery.
(b) Pregnancy
(1) In the event of pregnancy, an applicant may continue to exercise her privileges until the end of the 26th week of gestation only if the AeMC or AME considers that she is fit to do so.
(2) For holders of a class 1 medical certificate who are pregnant, an OML shall apply. Notwithstanding point MED.B.001, in that case, the OML may be imposed and removed by the AeMC or AME.
(3) An applicant may resume exercising her privileges after recovery following the end of the pregnancy.
AMC1 MED.B.045 Obstetrics and gynaecology
ED Decision 2019/002/R
(a) Gynaecological surgery
Applicants who have undergone a major gynaecological operation should be assessed as unfit. A fit assessment may be considered if recovery is complete, the applicant is asymptomatic, and the risk of
(b) Pregnancy
(1) A pregnant licence holder may be assessed as fit with an OML during the first 26 weeks of gestation following review of the obstetric evaluation by the AeMC or AME who should inform the medical assessor of the licensing authority.
(2) The AeMC or AME should provide written advice to the applicant and the supervising physician regarding potentially significant complications of pregnancy.
AMC2 MED.B.045 Obstetrics and gynaecology
ED Decision 2019/002/R
(a) Gynaecological surgery
Applicants who have undergone a major gynaecological operation should be assessed as unfit until recovery is complete, the applicant is asymptomatic, and the risk of secondary complication or recurrence is minimal.
(b) Pregnancy
(1) A pregnant licence holder may be assessed as fit during the first 26 weeks of gestation following satisfactory obstetric evaluation.
(2) Licence privileges may be resumed upon satisfactory confirmation of full recovery following confinement or termination of pregnancy.
MED.B.050 Musculoskeletal System
Regulation (EU) 2019/27
(a) Applicants who do not have sufficient sitting height, arm and leg length and muscular strength for the safe exercise of the privileges of the licence shall be assessed as unfit. However, where their sitting height, arm and leg length and muscular strength is sufficient for the safe exercise of the privileges in respect of a certain aircraft type, which can be demonstrated where necessary through a medical flight or a simulator flight test, the applicant may be assessed as fit and their privileges shall be limited accordingly.
(b) Applicants who do not have satisfactory functional use of the musculoskeletal system to enable them to safely exercise the privileges of the licence shall be assessed as unfit. However, where their functional use of the musculoskeletal system is satisfactory for the safe exercise the privileges in respect of a certain aircraft type, which may be demonstrated where necessary through a medical flight or a simulator flight test, the applicant may be assessed as fit and their privileges shall be limited accordingly.
(c ) In case of doubt arising in the context of the assessments referred to in points (a) and (b), applicants for a class 1 medical certificate shall be referred to the medical assessor of the licensing authority and applicants for a class 2 medical certificate shall be assessed in consultation with the medical assessor of the licensing authority.
AMC1 MED.B.050 Musculoskeletal system
ED Decision 2019/002/R
(a) Applicants with any significant sequelae from disease, injury or congenital abnormality affecting the bones, joints, muscles or tendons with or without surgery require full evaluation prior to a fit assessment.
(b) Applicants with inflammatory, infiltrative, traumatic or degenerative disease of the musculoskeletal system may be assessed as fit, provided the condition is in remission or is stable and the applicant is taking no disqualifying medication and has satisfactorily completed a medical flight or simulator flight test. Appropriate limitation(s) apply.
(c) Applicants with abnormal musculoskeletal system, including obesity, undertaking medical fight or flight simulator testing should satisfactorily perform all tasks required for the type of flight intended, including the emergency and evacuation procedures.
AMC2 MED.B.050 Musculoskeletal system
ED Decision 2019/002/R
(a) Applicants with any significant sequelae from disease, injury or congenital abnormality affecting the bones, joints, muscles or tendons with or without surgery should require full evaluation prior to a fit assessment.
(b) Applicants with inflammatory, infiltrative, traumatic or degenerative disease of the musculoskeletal system may be assessed as fit provided the condition is in remission or is stable and the applicant is taking no disqualifying medication and has satisfactorily completed a medical flight test. Appropriate limitation(s) may apply.
(c) Applicants with abnormal musculoskeletal system, including obesity, undertaking a medical flight test should satisfactorily perform all tasks required for the type of flight intended, including the emergency and evacuation procedures.
MED.B.055 Mental Health
Regulation (EU) 2019/27
(a) Comprehensive mental health assessment shall form part of the initial class 1 aero-medical examination.
(b) Drugs and alcohol screening shall form part of the initial class 1 aero-medical examination.
(c) Applicants with a mental or behavioural disorder due to use or misuse of alcohol or other psychoactive substances shall be assessed as unfit pending recovery and freedom from psychoactive substance use or misuse and subject to satisfactory psychiatric evaluation after successful treatment.
(d) Applicants with a clinical diagnosis or documented medical history of any of the following psychiatric conditions shall undergo satisfactory psychiatric evaluation before they may be assessed as fit:
(1) mood disorder;
(2) neurotic disorder;
(3) personality disorder;
(4) mental or behavioural disorder;
(5) misuse of a psychoactive substance.
(e) Applicants with a documented medical history of a single or repeated acts of deliberate self-harm or suicide attempt shall be assessed as unfit. However, they may be assessed as fit after satisfactory psychiatric evaluation.
(f) Aero-medical assessment
(1) Applicants for a class 1 medical certificate with any of the conditions specified in point (c), (d) or (e) shall be referred to the medical assessor of the licensing authority.
(2) The fitness of applicants for a class 2 medical certificate with any of the conditions specified in point (c), (d) or (e) shall be assessed in consultation with the medical assessor of the licensing authority.
(g) Applicants with a documented medical history or clinical diagnosis of schizophrenia, schizotypal or delusional disorder shall be assessed as unfit.
ED Decision 2019/002/R
(a) Mental health assessment as part of the initial class 1 aero-medical examination
(1) A comprehensive mental health assessment should be conducted and recorded taking into account social, environmental and cultural contexts.
(2) The applicant's history and symptoms of disorders that might pose a threat to flight safety should be identified and recorded.
(3) The mental health assessment should include assessment and documentation of:
(i) general attitudes to mental health, including understanding possible indications of reduced mental health in themselves and others;
(ii) coping strategies under periods of psychological stress or pressure in the past, including seeking advice from others;
(iii) childhood behavioural problems;
(iv) interpersonal and relationship issues;
(v) current work and life stressors; and
(vi) overt personality disorders.
(4) Where there are signs or is established evidence that an applicant may have a psychiatric or psychological disorder, the applicant should be referred for specialist opinion and advice.
(b) Mental health assessment as part of revalidation or renewal class 1 medical examination
(1) The assessment should include review and documentation of:
(i) current work and life stressors;
(ii) coping strategies under periods of psychological stress or pressure in the past, including seeking advice from others;
(iii) any difficulties with operational crew resource management (CRM);
(iv) any difficulties with employer and/or other colleagues and managers; and
(v) interpersonal and relationship issues, including difficulties with relatives, friends, and work colleagues.
(2) Where there are signs or is established evidence that an applicant may have a psychiatric or psychological disorder, the applicant should be referred for specialist opinion and advice.
(3) Established evidence should be verifiable information from an identifiable source related to the mental fitness or personality of a particular individual. Sources for this information can be accidents or incidents, problems in training or proficiency checks, behaviour or knowledge relevant to the safe exercise of the privileges of the applicable licence(s).
(c) Assessment of holders of a class 1 medical certificate referenced in MED.B.055(d)
Assessment of holders of a class 1 medical certificate referenced in MED.B.055(d) may require psychiatric and psychological evaluation as determined by the medical assessor of the licensing authority. A SIC limitation should be imposed in case of a fit assessment. Follow-up and removal of SIC limitation, as necessary, should be determined by the medical assessor of the licensing authority.
(d) Psychoactive substance testing
(1) Drug tests should screen for opioids, cannabinoids, amphetamines, cocaine, hallucinogens and sedative hypnotics. Following a risk assessment performed by the competent authority on the target population, screening tests may include additional drugs.
(2) For renewal/revalidation, random psychoactive substance screening test may be performed based on the risk assessment by the competent authority on the target population. If random psychoactive substance screening test is considered, it should be performed and reported in accordance with the procedures developed by the competent authority.
(3) In the case of a positive psychoactive substance screening result, confirmation should be required in accordance with national standards and procedures for psychoactive substance testing.
(4) In case of a positive confirmation test, a psychiatric evaluation should be undertaken before a fit assessment may be considered by the medical assessor of the licensing authority.
(e) Assessment and referral decisions
(1) Psychotic disorder
Applicants with a history, or the occurrence, of a functional psychotic disorder should be assessed as unfit. A fit assessment may be considered if a cause can be unequivocally identified as one which is transient, has ceased and the risk of recurrence is minimal.
(2) Organic mental disorder
Applicants with an organic mental disorder should be assessed as unfit. Once the cause has been treated, an applicant may be assessed as fit following satisfactory psychiatric evaluation.
(3) Psychoactive medication
Applicants who use psychoactive medication likely to affect flight safety should be assessed as unfit. If stability on maintenance psychoactive medication is confirmed, a fit assessment with an OML may be considered. If the dosage or type of medication is changed, a further period of unfit assessment should be required until stability is confirmed.
(4) Schizophrenia, schizotypal or delusional disorder
Applicants with an established history or clinical diagnosis of schizophrenia, schizotypal or delusional disorder may only be considered for a fit assessment if the medical assessor of the licensing authority concludes that the original diagnosis was inappropriate or inaccurate as confirmed by psychiatric evaluation, or, in the case of a single episode of delirium of which the cause was clear, provided that the applicant has suffered no permanent mental impairment.
(5) Mood disorder
Applicants with an established mood disorder should be assessed as unfit. After full recovery and after full consideration of the individual case, a fit assessment may be considered, depending on the characteristics and severity of the mood disorder.
(6) Neurotic, stress-related or somatoform disorder
Where there are signs or is established evidence that an applicant may have a neurotic, stress-related or somatoform disorder, the applicant should be referred for psychiatric or psychological opinion and advice.
(7) Personality or behavioural disorders
Where there are signs or is established evidence that an applicant may have a personality or behavioural disorder, the applicant should be referred for psychiatric or psychological opinion and advice.
(8) Disorders due to alcohol or other psychoactive substance(s) use or misuse
(i) Applicants with mental or behavioural disorders due to alcohol or other psychoactive substance(s) use or misuse, with or without dependency, should be assessed as unfit.
(ii) A fit assessment may be considered after a period of two years of documented sobriety or freedom from psychoactive substance use or misuse. At revalidation or renewal, a fit assessment may be considered earlier with an OML. Depending on the individual case, treatment and evaluation may include in-patient treatment of some weeks and inclusion into a support programme followed by ongoing checks, including drug and alcohol testing and reports resulting from the support programme, which may be required indefinitely.
(9) Deliberate self-harm and suicide attempt
Applicants who have carried out a single self-destructive action or repeated acts of deliberate self-harm or suicide attempt should be assessed as unfit. A fit assessment may be considered after full consideration of an individual case and may require psychiatric or psychological evaluation. Neuropsychological evaluation may also be required.
(10) Assessment
The assessment should take into consideration if the indication for the treatment, side effects and addiction risks of such treatment and the characteristics of the psychiatric disorder are compatible with flight safety.
(f) Specialist opinion and advice
(1) In case a specialist evaluation is needed, following the evaluation, the specialist should submit a written report to the AME, AeMC or medical assessor of the licensing authority as appropriate, detailing their opinion and recommendation.
(2) Psychiatric evaluations should be conducted by a qualified psychiatrist having adequate knowledge and experience in aviation medicine.
(3) The psychological opinion and advice should be based on a clinical psychological assessment conducted by a suitably qualified and accredited clinical psychologist with expertise and experience in aviation psychology.
(4) The psychological evaluation may include a collection of biographical data, the administration of aptitude as well as personality tests and clinical interview.
AMC2 MED.B.055 Mental health
ED Decision 2019/002/R
(a) Mental health assessment as part of class 2 aero-medical examination
(1) A mental health assessment should be conducted and recorded taking into account social, environmental and cultural contexts.
(2) The applicant's history and symptoms of disorders that might pose a threat to flight safety should be identified and recorded.
(3) Where there are signs or is established evidence that an applicant may have a psychiatric or psychological disorder, the applicant should be referred for specialist opinion and advice.
(4) Established evidence should be verifiable information from an identifiable source related to the mental fitness or personality of a particular individual. Sources for this information can be accidents or incidents, problems in training or proficiency checks, behaviour or knowledge relevant to the safe exercise of the privileges of the applicable licence(s).
(b) Assessment of holders of a class 2medical certificate referenced in MED.B.055(d)
Assessment of holders of a class 2 medical certificate referenced in MED.B.055(d) may require psychiatric and psychological evaluation as determined by the AME, AeMC or medical assessor of the licensing authority. Follow-up, as necessary, should be determined in consultation with the medical assessor of the licensing authority.
(c) Assessment and referral decisions
(1) Psychotic disorder
Applicants with a history, or the occurrence, of a functional psychotic disorder should be assessed as unfit. A fit assessment may be considered if a cause can be unequivocally identified as one which is transient, has ceased and the risk of recurrence is minimal.
(2) Organic mental disorder
Applicants with an organic mental disorder should be assessed as unfit. Once the cause has been treated, an applicant may be assessed as fit following satisfactory psychiatric evaluation.
(3) Schizophrenia, schizotypal or delusional disorder
Applicants with an established history or clinical diagnosis of schizophrenia, schizotypal or delusional disorder may only be considered for a fit assessment in consultation with the medical assessor of the licensing authority if the original diagnosis was inappropriate or inaccurate as confirmed by psychiatric evaluation, or, in the case of a single episode of delirium of which the cause was clear, provided that the applicant has suffered no permanent mental impairment.
(4) Mood disorder
Applicants with an established mood disorder should be assessed as unfit. After full recovery and after full consideration of the individual case, a fit assessment may be considered, depending on the characteristics and severity of the mood disorder.
(5) Neurotic, stress-related or somatoform disorder
Where there are signs or is established evidence that an applicant may have a neurotic, stress-related or somatoform disorder, the applicant should be referred for psychiatric opinion and advice.
(6) Personality or behavioural disorders
Where there are signs or is established evidence that an applicant may have a personality or behavioural disorder, the applicant should be referred for psychiatric opinion and advice.
(7) Psychoactive medication
Applicants who use psychoactive medication likely to affect flight safety should be assessed as unfit. If stability on maintenance psychoactive medication is confirmed, a fit assessment with an OSL or OPL may be considered. If the dosage or type of medication is changed, a further period of unfit assessment should be required until stability is confirmed.
(8) Disorders due to alcohol or other psychoactive substance(s) use or misuse
(i) Applicants with mental or behavioural disorders due to alcohol or other psychoactive substance(s) use or misuse, with or without dependency, should be assessed as unfit.
(ii) Drug and alcohol tests
(A) In the case of a positive drug or alcohol result, confirmation should be required in accordance with national procedures for drugs and alcohol testing.
(B) In case of a positive confirmation test, a psychiatric evaluation should be undertaken before a fit assessment may be considered.
(iii) A fit assessment may be considered after a period of two years of documented sobriety or freedom from psychoactive substance use or misuse. At revalidation or renewal, a fit assessment may be considered earlier with an OSL or OPL. Depending on the individual case, treatment and evaluation may include in-patient treatment of some weeks and inclusion into a support programme followed by ongoing checks, including drug and alcohol testing and reports resulting from the support programme, which may be required indefinitely.
(9) Deliberate self-harm
Applicants who have carried out a single self-destructive action or repeated acts of deliberate self-harm or suicide attempt should be assessed as unfit. A fit assessment may be considered after full consideration of an individual case and may require psychiatric or psychological evaluation. Neuropsychological evaluation may also be required.
(e) Specialist opinion and advice
(1) In case a specialist evaluation is needed, following the evaluation, the specialist should submit a written report to the AME, AeMC or medical assessor of the licensing authority as appropriate, detailing their opinion and recommendation.
(2) Psychiatric evaluations should be conducted by a qualified psychiatrist having adequate knowledge and experience in aviation medicine.
(3) The psychological opinion and advice should be based on a clinical psychological assessment conducted by a suitably qualified and accredited clinical psychologist with expertise and experience in aviation psychology.
(4) The psychological evaluation may include a collection of biographical data, the administration of aptitude as well as personality tests and clinical interview.
ED Decision 2019/002/R
(a) Symptoms of concern may include but are not limited to:
(1) use of alcohol or other psychoactive substances;
(2) loss of interest/energy;
(3) eating and weight changes;
(4) sleeping problems;
(5) low mood and, if present, any suicidal thoughts;
(6) family history of psychiatric disorders, particularly suicide;
(7) anger, agitation or high mood; and
(8) depersonalisation or loss of control.
(b) The following aspects should be taken into consideration when conducting the mental health examination:
(1) Appearance;
(2) Attitude;
(3) Behaviour;
(4) Mood;
(5) Speech;
(6) Thoughts process and content;
(7) Perception;
(8) Cognition;
(9) Insight; and
(10) Judgement.
ED Decision 2019/002/R
(a) Drugs and alcohol screening tests used should:
(1) provide information regarding medium-term consumption;
(2) be accepted on national level by the competent authority based on the availability and suitability for the scope mentioned in point(a)(1) above.
(b) Statistical data of the screening campaign mentioned in AMC1 MED.B.055(d)(1) should be made available to the Agency on a yearly basis.
ED Decision 2019/002/R
(a) The mental health assessment for class 2 applicants should include assessment and documentation of:
(1) general attitudes to mental health, including understanding possible indications of reduced mental health in themselves and others;
(2) coping strategies under periods of psychological stress or pressure in the past, including seeking advice from others;
(3) childhood behavioural problems;
(4) interpersonal and relationship issues, including difficulties with relatives, friends, and work colleagues;
(5) current work and life stressors, including difficulties with aviation operational environment; and
(6) overt personality disorders.
(b) In regard to symptoms of concern and aspects to be taken into consideration when conducting mental health examination for class 2 applicants, guidance presented in GM1 MED.B.055 should be used.
ED Decision 2019/002/R
Drugs and alcohol screening tests used should:
(a) provide information regarding medium-term consumption;
(b) be accepted on national level by the competent authority based on the availability and suitability with the scope mentioned in GM2 MED.B.055(a) above.
Regulation (EU) 2019/27
(a) Applicants with clinical diagnosis or a documented medical history of any of the following medical conditions shall be assessed as unfit:
(1) epilepsy, except in the cases referred to in points (1) and (2) of point (b);
(2) recurring episodes of disturbance of consciousness of uncertain cause.
(b) Applicants with clinical diagnosis or a documented medical history of any of the following medical conditions shall undergo further evaluation before they may be assessed as fit:
(1) epilepsy without recurrence after age 5;
(2) epilepsy without recurrence and off all treatment for more than 10 years;
(3) epileptiform EEG abnormalities and focal slow waves;
(4) progressive or non-progressive disease of the nervous system;
(5) inflammatory disease of the central or peripheral nervous system;
(6) migraine;
(7) a single episode of disturbance of consciousness of uncertain cause;
(8) loss of consciousness after head injury;
(9) penetrating brain injury;
(10) spinal or peripheral nerve injury;
(11) disorders of the nervous system due to vascular deficiencies including haemorrhagic and ischaemic events.
Applicants for a class 1 medical certificate shall be referred to the medical assessor of the licensing authority. The fitness of applicants for a class 2 medical certificate shall be assessed in consultation with the medical assessor of the licensing authority.
ED Decision 2019/002/R
(a) Epilepsy
(1) Applicants with a diagnosis of epilepsy should be assessed as unfit unless there is unequivocal evidence of a syndrome of benign childhood epilepsy associated with a very low risk of recurrence, and unless the applicant has been free of recurrence and off treatment for more than 10 years. One or more convulsive episode after the age of 5 should lead to unfitness. In the case of an acute symptomatic seizure, which is considered to have a very low risk of recurrence, a fit assessment may be considered after neurological evaluation.
(2) Applicants may be assessed as fit with an OML if:
(i) there is a history of a single afebrile epileptiform seizure;
(ii) there has been no recurrence after at least 10 years off treatment;
(iii) there is no evidence of continuing predisposition to epilepsy.
(b) EEG
(1) Electroencephalography is required when indicated by the applicant’s history or on clinical grounds.
(2) Applicants with epileptiform paroxysmal EEG abnormalities and focal slow waves should be assessed as unfit.
(c) Neurological disease
Applicants with any disease of the nervous system which is likely to cause a hazard to flight safety should be assessed as unfit. However, in certain cases, including cases of minor functional losses associated withstable disease, a fit assessment may be considered after full evaluation which should include a medical flight test which may be conducted in a flight simulation training device.
(d) Migraine
Applicants with an established diagnosis of migraine or other severe periodic headaches likely to cause a hazard to flight safety should be assessed as unfit. A fit assessment may be considered after full evaluation. The evaluation should take into account at least the following: auras, visual field loss, frequency, severity, therapy. Appropriate limitation(s) may apply.
(e) Episode of disturbance of consciousness
In the case of a single episode of disturbance of consciousness, which can be satisfactorily explained, a fit assessment may be considered, but applicants experiencing a recurrence should be assessed as unfit.
(f) Head injury
Applicants with a head injury which was severe enough to cause loss of consciousness or is associated with penetrating brain injury should be evaluated by a neurologist. A fit assessment may be considered if there has been a full recovery and the risk of epilepsy is sufficiently low.
(g) Spinal or peripheral nerve injury
Applicants with a history or diagnosis of spinal or peripheral nerve injury or a disorder of the nervous system due to a traumatic injury should be assessed as unfit. A fit assessment may be considered if neurological evaluation is satisfactory and the conditions of AMC1 MED.B.050 are satisfied.
(h) Vascular deficiencies
Applicants with a disorder of the nervous system due to vascular deficiencies including haemorrhagic and ischaemic events should be assessed as unfit. A fit assessment may be considered if neurological evaluation is satisfactory and the conditions of AMC1 MED.B.050 are satisfied. A cardiological evaluation and medical flight test should be undertaken for applicants with residual deficiencies.
ED Decision 2019/002/R
(a) Epilepsy
Applicants may be assessed as fit if:
(1) there is a history of a single afebrile epileptiform seizure, considered to have a very low risk of recurrence;
(2) there has been no recurrence after at least 10 years off treatment; and
(3) there is no evidence of continuing predisposition to epilepsy.
(b) Neurological disease
Applicants with any disease of the nervous system which is likely to cause a hazard to flight safety should be assessed as unfit. However, in certain cases, including cases of functional loss associated with stable disease, a fit assessment may be considered after full evaluation which should include a medical flight test which may be conducted in a flight simulation training device.
(c) Migraine
Applicants with an established diagnosis of migraine or other severe periodic headaches likely to cause a hazard to flight safety should be assessed as unfit. A fit assessment may be considered after full evaluation. The evaluation should take into account at least the following: auras, visual field loss, frequency, severity, and therapy. Appropriate limitation(s) may apply.
(d) Head injury
Applicants with a head injury which was severe enough to cause loss of consciousness or is associated with penetrating brain injury may be assessed as fit if there has been a full recovery and the risk of epilepsy is sufficiently low. An evaluation by a neurologist may be required depending on the staging of the original injury.
(e) Spinal or peripheral nerve injury
Applicants with a history or diagnosis of spinal or peripheral nerve injury or a disorder of the nervous system due to a traumatic injury should be assessed as unfit. A fit assessment may be considered if neurological evaluation is satisfactory and the conditions of AMC2 MED.B.050 are satisfied.
(f) Vascular deficiencies
Applicants with a disorder of the nervous system due to vascular deficiencies including haemorrhagic and ischaemic events should be assessed as unfit. A fit assessment may be considered if neurological evaluation is satisfactory and the provisions of AMC2 MED.B.050 are met. A cardiological evaluation and medical flight test should be undertaken for applicants with residual deficiencies.
Regulation (EU) 2019/27
(a) Examination
(1) For a class 1 medical certificate:
(i) a comprehensive eye examination shall form part of the initial examination and shall be undertaken when clinically indicated and periodically, depending on the refraction and the functional performance of the eye.
(ii) a routine eye examination shall form part of all revalidation and renewal examinations.
(2) For a class 2 medical certificate:
(i) a routine eye examination shall form part of the initial and all revalidation and renewal examinations.
(ii) a comprehensive eye examination shall be undertaken when clinically indicated.
(b) Visual acuity
(1) For a class 1 medical certificate:
(i) Distant visual acuity, with or without correction, shall be 6/9 (0,7) or better in each eye separately and visual acuity with both eyes shall be 6/6 (1,0) or better.
(ii) At the initial examination, applicants with substandard vision in one eye shall be assessed as unfit.
(iii) At revalidation and renewal examinations, notwithstanding point (b)(1)(i), applicants with acquired substandard vision in one eye or acquired monocularity shall be referred to the medical assessor of the licensing authority and may be assessed as fit subject to a satisfactory ophthalmological evaluation.
(2) For a class 2 medical certificate:
(i) Distant visual acuity, with or without correction, shall be 6/12 (0,5) or better in each eye separately and visual acuity with both eyes shall be 6/9 (0,7) or better.
(ii) Notwithstanding point (b)(2)(i), applicants with substandard vision in one eye or monocularity may be assessed as fit, in consultation with the medical assessor of the licensing authority and subject to a satisfactory ophthalmological evaluation.
(3) Applicants shall be able to read an N5 chart or equivalent at 30-50 cm and an N14 chart or equivalent at 100 cm, if necessary with correction.
(c) Refractive error and anisometropia
(1) Applicants with refractive errors or anisometropia may be assessed as fit subject to satisfactory ophthalmic evaluation.
(2) Notwithstanding point (c)(1), applicants for a class 1 medical certificate with any of the following medical conditions shall be referred to the medical assessor of the licensing authority and may be assessed as fit subject to a satisfactory ophthalmological evaluation:
(i) myopia exceeding –6.0 dioptres;
(ii) astigmatism exceeding 2.0 dioptres;
(iii) anisometropia exceeding 2.0 dioptres.
(3) Notwithstanding point (c)(1), applicants for a class 1 medical certificate with hypermetropia exceeding +5.0 dioptres shall be referred to the medical assessor of the licensing authority and may be assessed as fit subject to a satisfactory ophthalmological evaluation, provided that there are adequate fusional reserves, normal intraocular pressures and anterior angles and no significant pathology has been demonstrated. Notwithstanding point (b)(1)(i), corrected visual acuity in each eye shall be 6/6 or better.
(4) Applicants with a clinical diagnosis of keratoconus may be assessed as fit subject to a satisfactory examination by an ophthalmologist. Such applicants for a class 1 medical certificate shall be referred to the medical assessor of the licensing authority.
(d) Binocular function
(1) Applicants for a class 1 medical certificate shall be assessed as unfit, where they do not have normal binocular function and that medical condition is likely to jeopardise the safe exercise of the privileges of the license, taking account of any appropriate corrective measures where relevant.
(2) Applicants with diplopia shall be assessed as unfit.
(e) Visual fields
Applicants for a class 1 medical certificate shall be assessed as unfit, where they do not have normal fields of vision and that medical condition is likely to jeopardise the safe exercise of the privileges of the license, taking account of any appropriate corrective measures where relevant.
(f) Eye surgery
Applicants who have undergone eye surgery shall be assessed as unfit. However, they may be assessed as fit after full recovery of their visual function and subject to satisfactory ophthalmological evaluation.
(g) Spectacles and contact lenses
(1) If satisfactory visual function is achieved only with the use of correction, the spectacles or contact lenses shall provide optimal visual function, be well-tolerated and suitable for aviation purposes.
(2) No more than one pair of spectacles shall be used to meet the visual requirements when exercising the privileges of the applicable licence(s).
(3) For distant vision, spectacles or contact lenses shall be worn when exercising the privileges of the applicable licence(s).
(4) For near vision, a pair of spectacles shall be kept available when exercising the privileges of the applicable licence(s).
(5) A spare set of similarly correcting spectacles, for distant or near vision as applicable, shall be readily available for immediate use when exercising the privileges of the applicable licence(s).
(6) If contact lenses are worn when exercising the privileges of the applicable licence(s), they shall be for distant vision, monofocal, and non-tinted and well-tolerated.
(7) Applicants with a large refractive error shall use contact lenses or high-index spectacle lenses.
(8) Orthokeratological lenses shall not be used.
ED Decision 2019/002/R
(a) Eye examination
(1) At each aero-medical examination, an assessment of the visual fitness should be undertaken and the eyes should be examined with regard to possible pathology.
(2) All abnormal and doubtful cases should be referred to an ophthalmologist. Conditions which indicate ophthalmological examination include but are not limited to a substantial decrease in the uncorrected visual acuity, any decrease in best corrected visual acuity and/or the occurrence of eye disease, eye injury, or eye surgery.
(3) Where specialist ophthalmological examinations are required for any significant reason, this should be imposed as a limitation on the medical certificate.
(4) The possible cumulative effect of more than one eye condition should be evaluated by an ophthalmologist.
(b) Comprehensive eye examination
A comprehensive eye examination by an eye specialist is required at the initial examination. All abnormal and doubtful cases should be referred to an ophthalmologist. The examination should include:
(1) history;
(2) visual acuities near, intermediate and distant vision (uncorrected and with best optical correction if needed);
(3) examination of the external eye, anatomy, media (slit lamp) and fundoscopy;
(4) ocular motility;
(5) binocular vision;
(6) visual fields;
(7) tonometry on clinical indication;
(8) objective refraction: hyperopic initial applicants with a hyperopia of more than +2 dioptres and under the age of 25 should undergo objective refraction in cycloplegia;
(9) assessment of mesopic contrast sensitivity; and
(10) colour vision.
(c) Routine eye examination
A routine eye examination may be performed by an AME and should include:
(1) history;
(2) visual acuities - near, intermediate and distant vision (uncorrected and with best optical correction if needed);
(3) examination of the external eye, anatomy, media and fundoscopy; and
(4) further examination on clinical indication.
(d) Refractive error and anisometropia
(1) Applicants with the following conditions may be assessed as fit subject to satisfactory ophthalmic evaluation and provided that optimal correction has been considered and no significant pathology is demonstrated:
(i) hypermetropia not exceeding +5.0 dioptres;
(ii) myopia not exceeding –6.0 dioptres;
(iii) astigmatism not exceeding 2.0 dioptres;
(iv) anisometropia not exceeding 2.0 dioptres.
(2) Applicants should wear contact lenses if:
(i) hypermetropia exceeds +5.0 dioptres;
(ii) anisometropia exceeds 3.0 dioptres.
(3) An evaluation by an eye specialist should be undertaken 5-yearly if:
(i) the refractive error is between –3.0 and –6.0 dioptres or +3 and +5 dioptres;
(ii) astigmatism or anisometropia is between 2.0 and 3.0 dioptres.
(4) An evaluation by an eye specialist should be undertaken 2-yearly if:
(i) the refractive error is greater than –6.0 dioptres or +5.0 dioptres;
(ii) astigmatism or anisometropia exceeds 3.0 dioptres.
(e) Uncorrected visual acuity
No limits apply to uncorrected visual acuity.
(f) Visual acuity
(1) Reduced vision in one eye or monocularity: Applicants for revalidation or renewal with reduced central vision or acquired loss of vision in one eye may be assessed as fit with an OML if:
(i) the binocular visual field or, in the case of monocularity, the monocular visual field is acceptable;
(ii) in the case of monocularity, a period of adaptation time has passed from the known point of visual loss, during which the applicant should be assessed as unfit;
(iii) the unaffected eye achieves distant visual acuity of 6/6 (1,0) corrected or uncorrected;
(iv) the unaffected eye achieves intermediate visual acuity of N14 and N5 for near;
(v) the underlying pathology is acceptable according to ophthalmological assessment and there is no significant ocular pathology in the unaffected eye; and
(vi) a medical flight test is satisfactory.
(2) Visual fields
Applicants with a visual field defect, who do not have reduced central vision or acquired loss of vision in one eye, may be assessed as fit if the binocular visual field is normal.
(g) Keratoconus
Applicants with keratoconus may be assessed as fit if the visual requirements are met with the use of corrective lenses and periodic evaluation is undertaken by an ophthalmologist.
(h) Binocular function
Applicants with heterophoria (imbalance of the ocular muscles) exceeding:
(1) at 6 metres:
2.0 prism dioptres in hyperphoria,
10.0 prism dioptres in esophoria,
8.0 prism dioptres in exophoria
and
(2) at 33 centimetres:
1.0 prism dioptre in hyperphoria,
8.0 prism dioptres in esophoria,
12.0 prism dioptres in exophoria
should be assessed as unfit. A fit assessment may be considered if an orthoptic evaluation demonstrates that the fusional reserves are sufficient to prevent asthenopia and diplopia.
(i) Eye surgery
The assessment after eye surgery should include an ophthalmological examination.
(1) After refractive surgery, a fit assessment may be considered, provided that:
(i) stability of refraction of less than 0.75 dioptres variation diurnally has been achieved;
(ii) examination of the eye shows no post-operative complications;
(iii) glare sensitivity is within normal standards;
(iv) mesopic contrast sensitivity is not impaired;
(v) an evaluation is undertaken by an eye specialist.
(2) Following intraocular lens surgery, including cataract surgery, a fit assessment may be considered once recovery is complete and the visual requirements are met with or without correction. Intraocular lenses should be monofocal and should not impair colour vision and night vision.
(3) Retinal surgery entails unfitness. A fit assessment may be considered 6 months after surgery, or earlier if recovery is complete. A fit assessment may also be considered earlier after retinal laser therapy. Regular follow-up by an ophthalmologist should be carried out.
(4) Glaucoma surgery entails unfitness. A fit assessment may be considered 6 months after surgery or earlier if recovery is complete. Regular follow-up by an ophthalmologist should be carried out.
(j) Visual correction
Correcting lenses should permit the licence holder to meet the visual requirements at all distances.
ED Decision 2019/002/R
(a) Eye examination
(1) At each aero-medical revalidation examination an assessment of the visual fitness of the applicant should be undertaken and the eyes should be examined with regard to possible pathology. Conditions which indicate further ophthalmological examination include but are not limited to a substantial decrease in the uncorrected visual acuity, any decrease in best corrected visual acuity and/or the occurrence of eye disease, eye injury, or eye surgery.
(2) At the initial assessment, the examination should include:
(i) history;
(ii) visual acuities near, intermediate and distant vision (uncorrected and with best optical correction if needed);
(iii) examination of the external eye, anatomy, media and fundoscopy;
(iv) ocular motility;
(v) binocular vision;
(vi) visual fields;
(vii) colour vision;
(viii) further examination on clinical indication.
(3) At the initial assessment the applicant should submit a copy of the recent spectacle prescription if visual correction is required to meet the visual requirements.
(b) Routine eye examination
A routine eye examination should include:
(1) history;
(2) visual acuities - near, intermediate and distant vision (uncorrected and with best optical correction if needed);
(3) examination of the external eye, anatomy, media and fundoscopy;
(4) further examination on clinical indication.
(c) Visual acuity
Reduced vision in one eye or monocularity: Applicants with reduced vision or loss of vision in one eye may be assessed as fit if:
(1) the binocular visual field or, in the case of monocularity, the monocular visual field is acceptable;
(2) in the case of monocularity, a period of adaptation time has passed from the known point of visual loss, during which the applicant should be assessed as unfit;
(3) the unaffected eye achieves distant visual acuity of 6/6 (1,0), corrected or uncorrected;
(4) the unaffected eye achieves intermediate visual acuity of N14 or equivalent and N5 or equivalent for near (Refer to GM1 MED.B.070);
(5) there is no significant ocular pathology in the unaffected eye; and
(6) a medical flight test is satisfactory.
(d) Binocular function
Reduced stereopsis, abnormal convergence not interfering with near vision and ocular misalignment where the fusional reserves are sufficient to prevent asthenopia and diplopia may be acceptable.
(e) Eye surgery
(1) The assessment after eye surgery should include an ophthalmological examination.
(2) After refractive surgery a fit assessment may be considered provided that there is satisfactory stability of refraction, there are no post-operative complications and no increase in glare sensitivity.
(3) After cataract, retinal or glaucoma surgery a fit assessment may be considered once recovery is complete and the visual requirements are met with or without correction.
(f) Visual correction
Correcting lenses should permit the licence holder to meet the visual requirements at all distances.
ED Decision 2019/002/R
COMPARISON OF DIFFERENT READING CHARTS (APPROXIMATE FIGURES)
(a) Test distance: 40 cm
|
Decimal |
Nieden |
Jäger |
Snellen |
N |
Parinaud |
|
1,0 |
1 |
2 |
1,5 |
3 |
2 |
|
0,8 |
2 |
3 |
2 |
4 |
3 |
|
0,7 |
3 |
4 |
2,5 |
|
|
|
0,6 |
4 |
5 |
3 |
5 |
4 |
|
0,5 |
5 |
5 |
|
6 |
5 |
|
0,4 |
7 |
9 |
4 |
8 |
6 |
|
0,35 |
8 |
10 |
4,5 |
|
8 |
|
0,32 |
9 |
12 |
5,5 |
10 |
10 |
|
0,3 |
9 |
12 |
|
12 |
|
|
0,25 |
9 |
12 |
|
14 |
|
|
0,2 |
10 |
14 |
7,5 |
16 |
14 |
|
0,16 |
11 |
14 |
12 |
20 |
|
(b) Test distance: 80 cm
|
Decimal |
Nieden |
Jäger |
Snellen |
N |
Parinaud |
|
1,2 |
4 |
5 |
3 |
5 |
4 |
|
1,0 |
5 |
5 |
|
6 |
5 |
|
0,8 |
7 |
9 |
4 |
8 |
6 |
|
0,7 |
8 |
10 |
4,5 |
|
8 |
|
0,63 |
9 |
12 |
5,5 |
10 |
10 |
|
0,6 |
9 |
12 |
|
12 |
10 |
|
0,5 |
9 |
12 |
|
14 |
10 |
|
0,4 |
10 |
14 |
7,5 |
16 |
14 |
|
0,32 |
11 |
14 |
12 |
20 |
14 |
ED Decision 2019/002/R
EYE SPECIALIST
The term ‘eye specialist’ refers to an ophthalmologist or a vision care specialist qualified in optometry and trained to recognise pathological conditions.
Regulation (EU) 2019/27
(a) Applicants shall be assessed as unfit, where they cannot demonstrate their ability to readily perceive the colours that are necessary for the safe exercise of the privileges of the licence.
(b) Examination and assessment
(1) Applicants shall be subjected to the Ishihara test for the initial issue of a medical certificate. Applicants who pass that test may be assessed as fit.
(2) For a class 1 medical certificate:
(i) Applicants who do not pass the Ishihara test shall be referred to the medical assessor of the licensing authority and shall undergo further colour perception testing to establish whether they are colour safe.
(ii) Applicants shall be normal trichromats or shall be colour safe.
(iii) Applicants who fail further colour perception testing shall be assessed as unfit.
(3) For a class 2 medical certificate:
(i) Applicants who do not pass the Ishihara test shall undergo further colour perception testing to establish whether they are colour safe.
(ii) Applicants who do not have satisfactory perception of colours shall be limited to exercising the privileges of the applicable licence in daytime only.
ED Decision 2019/002/R
(a) At revalidation and renewal examinations, colour vision should be tested on clinical indication.
(b) The Ishihara test (24 plate version) is considered passed if the first 15 plates, presented in a random order, are identified without error.
(c) Those failing the Ishihara test should be examined either by:
(1) anomaloscopy (Nagel or equivalent). This test is considered passed if the colour match is trichromatic and the matching range is 4 scale units or less, or if the anomalous quotient is acceptable; or by
(2) lantern testing with a Spectrolux, Beynes or Holmes-Wright lantern. This test is considered passed if the applicant passes without error a test with accepted lanterns.
(3) Colour Assessment and Diagnosis (CAD) test. This test is considered passed if the threshold is less than 6 standard normal (SN) units for deutan deficiency, or less than 12 SN units for protan deficiency. A threshold greater than 2 SN units for tritan deficiency indicates an acquired cause which should be investigated.
ED Decision 2019/002/R
(a) Colour vision should be tested on clinical indication at revalidation and renewal examinations.
(b) The Ishihara test (24 plate version) is considered passed if the first 15 plates, presented in a random order, are identified without error.
(c) Those failing the Ishihara test should be examined either by:
(1) anomaloscopy (Nagel or equivalent). This test is considered passed if the colour match is trichromatic and the matching range is 4 scale units or less, or if the anomalous quotient is acceptable; or by
(2) lantern testing with a Spectrolux, Beynes or Holmes-Wright lantern. This test is considered passed if the applicant passes without error a test with accepted lanterns.
(3) Colour Assessment and Diagnosis (CAD) test. This test is considered passed if the threshold is less than 6 standard normal (SN) units for deutan deficiency, or less than 12 SN units for protan deficiency. A threshold greater than 2 SN units for tritan deficiency indicates an acquired cause which should be investigated.
MED.B.080 Otorhinolaryngology (ENT)
Regulation (EU) 2019/27
(a) Examination
(1) Applicants’ hearing shall be tested at all examinations.
(i) For a class 1 medical certificate, and for a class 2 medical certificate when an instrument rating or en route instrument rating is to be added to the licence, hearing shall be tested with pure-tone audiometry at the initial examination, then every 5 years until the licence holder reaches the age of 40 and then every 2 years thereafter.
(ii) When tested on a pure-tone audiometer, initial applicants shall not have a hearing loss of more than 35 dB at any of the frequencies 500, 1 000 or 2 000 Hz, or more than 50 dB at 3 000 Hz, in either ear separately. Applicants for revalidation or renewal with greater hearing loss shall demonstrate satisfactory functional hearing ability.
(2) A comprehensive ear, nose and throat examination shall be undertaken for the initial issue of a class 1 medical certificate and periodically thereafter when clinically indicated.
(b) Applicants with any of the following medical conditions shall undergo further examination to establish that the medical condition does not interfere with the safe exercise of the privileges of the applicable licence(s):
(1) hypoacusis;
(2) an active pathological process of the internal or middle ear;
(3) unhealed perforation or dysfunction of the tympanic membrane(s);
(4) dysfunction of the Eustachian tube(s);
(5) disturbance of vestibular function;
(6) significant restriction of the nasal passages;
(7) sinus dysfunction;
(8) significant malformation or significant infection of the oral cavity or upper respiratory tract;
(9) significant disorder of speech or voice;
(10) any sequelae of surgery of the internal or middle ear.
(c) Aero-medical assessment
(1) Applicants for a class 1 medical certificate with any of the medical conditions specified in points (1), (4) and (5) of point (b) shall be referred to the medical assessor of the licensing authority.
(2) The fitness of applicants for a class 2 medical certificate with any of the medical conditions specified in point (4) and (5) of point (b) shall be assessed in consultation with the medical assessor of the licensing authority.
(3) The fitness of applicants for a class 2 medical certificate for an instrument rating or en route instrument rating to be added to the licence with the medical condition specified in point (1) of point (b) shall be assessed in consultation with the medical assessor of the licensing authority.
AMC1 MED.B.080 Otorhinolaryngology (ENT)
ED Decision 2019/002/R
(a) Hearing
(1) Applicants should understand correctly conversational speech when tested with each ear at a distance of 2 metres from and with the applicant’s back turned towards the AME.
(2) Applicants with hypoacusis may be assessed as fit if a speech discrimination test or functional flight deck hearing test demonstrates satisfactory hearing ability. A vestibular function test may be appropriate.
(3) If the hearing requirements can only be met with the use of hearing aids, the hearing aids should provide optimal hearing function, be well tolerated and suitable for aviation purposes.
(b) Comprehensive ENT examination
A comprehensive ENT examination should include:
(1) history;
(2) clinical examination including otoscopy, rhinoscopy, and examination of the mouth and throat;
(3) tympanometry or equivalent;
(4) clinical examination of the vestibular system.
(c) Ear conditions
(1) Applicants with an active pathological process of the internal or middle ear should be assessed as unfit. A fit assessment may be considered once the condition has stabilised or there has been a full recovery.
(2) Applicants with an unhealed perforation or dysfunction of the tympanic membranes should be assessed as unfit. An applicant with a single dry perforation of non-infectious origin and which does not interfere with the normal function of the ear may be considered for a fit assessment.
(d) Vestibular disturbance
Applicants with disturbance of vestibular function should be assessed as unfit. A fit assessment may be considered after full recovery. The presence of spontaneous or positional nystagmus requires complete vestibular evaluation by specialist. Applicants with significant abnormal caloric or rotational vestibular responses should be assessed as unfit. Abnormal vestibular responses should be assessed in their clinical context.
(e) Sinus dysfunction
Applicants with any dysfunction of the sinuses should be assessed as unfit until there has been full recovery.
(f) Oral/upper respiratory tract infections
Applicants with a significant infection of the oral cavity or upper respiratory tract should be assessed as unfit. A fit assessment may be considered after full recovery.
(g) Speech disorder
Applicants with a significant disorder of speech or voice should be assessed as unfit.
(h) Air passage restrictions
Applicants with significant restriction of the nasal air passage on either side, or significant malformation of the oral cavity or upper respiratory tract may be assessed as fit if ENT evaluation is satisfactory.
(i) Eustachian tube(s)
Applicants with permanent dysfunction of the Eustachian tube(s) may be assessed as fit if ENT evaluation is satisfactory.
(j) Sequelae of surgery of the internal or middle ear
Applicants with sequelae of surgery of the internal or middle ear should be assessed as unfit until recovery is complete, the applicant is asymptomatic, and the risk of secondary complication is minimal.
AMC2 MED.B.080 Otorhinolaryngology (ENT)
ED Decision 2019/002/R
(a) Hearing
(1) Applicants should understand correctly conversational speech when tested with each ear at a distance of 2 metres from and with the applicant’s back turned towards the AME.
(2) Applicants with hypoacusis may be assessed as fit if a speech discrimination test or functional cockpit hearing test demonstrates satisfactory hearing ability.
(3) If the hearing requirements can be met only with the use of hearing aids, the hearing aids should provide optimal hearing function, be well tolerated and suitable for aviation purposes.
(4) Applicants with profound deafness or major disorder of speech, or both, may be assessed as fit with an SSL, such as ‘limited to areas and operations where the use of radio is not mandatory’. The aircraft should be equipped with appropriate alternative warning devices in lieu of sound warnings.
(b) Examination
An ENT examination should form part of all initial, revalidation and renewal examinations.
(c) Ear conditions
(1) Applicants with an active pathological process of the internal or middle ear should be assessed as unfit until the condition has stabilised or there has been a full recovery.
(2) Applicants with an unhealed perforation or dysfunction of the tympanic membranes should be assessed as unfit. An applicant with a single dry perforation of non-infectious origin which does not interfere with the normal function of the ear may be considered for a fit assessment.
(d) Vestibular disturbance
Applicants with disturbance of vestibular function should be assessed as unfit pending full recovery.
(e) Sinus dysfunction
Applicants with any dysfunction of the sinuses should be assessed as unfit pending full recovery.
(f) Oral/upper respiratory tract infections
Applicants with a significant infection of the oral cavity or upper respiratory tract should be assessed as unfit. A fit assessment may be considered after full recovery.
(g) Speech disorder
Applicants with a significant disorder of speech or voice should be assessed as unfit.
(h) Air passage restrictions
Applicants with significant restriction of the nasal air passage on either side, or significant malformation of the oral cavity or upper respiratory tract may be assessed as fit if ENT evaluation is satisfactory.
(i) Eustachian tube dysfunction
Applicants with permanent dysfunction of the Eustachian tube(s) may be assessed as fit if ENT evaluation is satisfactory.
(j) Sequelae of surgery of the internal or middle ear
Applicants with sequelae of surgery of the internal or middle ear should be assessed as unfit until recovery is complete, the applicant is asymptomatic, and the risk of secondary complication is minimal.
GM1 MED.B.080 Otorhinolaryngology (ENT)
ED Decision 2019/002/R
PURE TONE AUDIOGRAM
The pure tone audiogram may also cover the 4 000 Hz frequency for early detection of decrease in hearing.
GM2 MED.B.080 Otorhinolaryngology (ENT)
ED Decision 2019/002/R
PURE TONE AUDIOGRAM
The pure tone audiogram may also cover the 4 000 Hz frequency for early detection of decrease in hearing.
Regulation (EU) 2019/27
Applicants shall be assessed as unfit, where they have an established dermatological condition which is likely to jeopardise the safe exercise of the privileges of the licence.
ED Decision 2019/002/R
(a) If doubt exists about the fitness of applicants with eczema (exogenous and endogenous), severe psoriasis, bacterial infections, drug induced or bullous eruptions or urticaria, the AME should refer the case to the medical assessor of the licensing authority.
(b) Systemic effects of radiant or pharmacological treatment for a dermatological condition should be reviewed before a fit assessment may be considered.
(c) In cases where a dermatological condition is associated with a systemic illness, full consideration should be given to the underlying illness before a fit assessment may be considered.
ED Decision 2019/002/R
In cases where a dermatological condition is associated with a systemic illness, full consideration should be given to the underlying illness before a fit assessment may be considered.
Regulation (EU) 2019/27
(a) Before further consideration is given to their application, applicants with primary or secondary malignant disease shall undergo satisfactory oncological evaluation. Such applicants for a class 1 medical certificate shall be referred to the medical assessor of the licensing authority. Such applicants for a class 2 medical certificate shall be assessed in consultation with the medical assessor of the licensing authority.
(b) Applicants with a documented medical history or clinical diagnosis of an intracerebral malignant tumour shall be assessed as unfit.
ED Decision 2019/002/R
(a) Applicants who have been diagnosed with a malignant disease may be assessed as fit provided that:
(1) after primary treatment, there is no evidence of residual malignant disease likely to jeopardise flight safety;
(2) time appropriate to the type of tumour and primary treatment has elapsed;
(3) the risk of inflight incapacitation from a recurrence or metastasis is sufficiently low;
(4) there is no evidence of short or long-term sequelae from treatment. Special attention should be paid to applicants who have received anthracycline chemotherapy;
(5) satisfactory oncology follow-up reports are provided to the medical assessor of the licensing authority.
(b) An OML should be applied as appropriate.
(c) Applicants receiving ongoing chemotherapy or radiation treatment should be assessed as unfit.
(d) Applicants with pre-malignant conditions of the skin may be assessed as fit if treated or excised as necessary and there is regular follow-up.
ED Decision 2019/002/R
(a) Applicants who have been diagnosed with a malignant disease may be considered for a fit assessment provided that:
(1) after primary treatment, there is no evidence of residual malignant disease likely to jeopardise flight safety;
(2) time appropriate to the type of tumour and primary treatment has elapsed;
(3) the risk of in-flight incapacitation from a recurrence or metastasis is sufficiently low;
(4) there is no evidence of short or long-term sequelae from treatment that may jeopardise flight safety;
(5) arrangements for an oncological follow-up have been made for an appropriate period of time.
(b) Applicants receiving ongoing chemotherapy or radiation treatment should be assessed as unfit.
(c) Applicants with pre-malignant conditions of the skin may be assessed as fit if treated or excised as necessary and there is a regular follow-up.