EASA 1178/2011 forordningen

LIMITATION CODES

(a) The following abbreviations for limitations codes should be used on the medical certificates as applicable:

(b) The abbreviations for the limitation codes should be explained to the holder of a medical certificate as follows:

(1) TML Time limitation

The period of validity of the medical certificate is limited to the duration as shown on the medical certificate. This period of validity commences on the date of the medical examination. Any period of validity remaining on the previous medical certificate is no longer valid. The holder of the medical certificate should present themselves for re-examination when advised and should follow any medical recommendations.

(2) VDL Wear corrective lenses and carry a spare set of spectacles

Correction for defective distant vision: whilst exercising the privileges of the licence, the holder of the medical certificate should wear spectacles or contact lenses that correct for defective distant vision as examined and approved by the AeMC, AME or GMP. Contact lenses may not be worn until cleared to do so by the AeMC, AME or GMP. A spare set of spectacles, approved by the AeMC, AME or GMP, should be readily available.

(3) VML Wear multifocal spectacles and carry a spare set of spectacles

Correction for defective distant, intermediate and near vision: whilst exercising the privileges of the licence, the holder of the medical certificate should wear spectacles that correct for defective distant, intermediate and near vision as examined and approved by the AeMC, AME or GMP. Contact lenses or full frame spectacles, when either correct for near vision only, may not be worn. A spare set of spectacles, approved by the AeMC, AME or GMP, should be readily available.

(4) VNL Have available corrective spectacles and carry a spare set of spectacles

Correction for defective near vision: whilst exercising the privileges of the licence, the holder of the medical certificate should have readily available spectacles that correct for defective near vision as examined and approved by the AeMC, AME or GMP. Contact lenses or full frame spectacles, when either correct for near vision only, may not be worn. A spare set of spectacles, approved by the AeMC, AME or GMP, should be readily available.

(5) CCL Wear contact lenses that correct for defective distant vision

Correction for defective distant vision: whilst exercising the privileges of the licence, the holder of a medical certificate should wear contact lenses that correct for defective distant vision, as examined and approved by the AeMC, AME or GMP. A spare set of similarly correcting spectacles, approved by the AeMC, AME or GMP, should be readily available for immediate use whilst exercising the privileges of the licence.

(6) VCL Valid by day only

This limitation allows holders of a class 2 or LAPL medical certificate with varying degrees of colour deficiency, to exercise the privileges of their licence by daytime only.

(7) RXO Specialist ophthalmological examination(s)

Specialist ophthalmological examination(s), other than the examinations stipulated in Part-MED, are required for a significant reason.

(8) SIC Specific regular medical examination(s) contact the medical assessor of the licensing authority

This limitation requires the AeMC, or AME to contact the medical assessor of the licensing authority before embarking upon a revalidation or renewal aero-medical assessment. The limitation is likely to concern a medical history or additional examination(s) which the AeMC or AME should be aware of prior to undertaking the assessment.

(9) HAL Wear hearing aid(s)

Whilst exercising the privileges of the licence, the holder of the medical certificate should use hearing aid(s) that compensate for defective hearing as examined and approved by the AeMC or AME. A spare set of batteries should be readily available.

(10) APL Valid only with approved prosthesis

This limitation applies to the holder of a medical certificate with a musculoskeletal condition when a medical flight test or a flight simulator test has shown that the use of a prosthesis is required to safely exercise the privileges of the licence. The prosthesis to be used should be approved.

(11) AHL Valid only with approved hand controls

This limitation applies to the holder of a medical certificate who has a limb deficiency or other anatomical problem which had been shown by a medical flight test or flight simulator testing to be acceptable but to require the aircraft to be equipped with suitable, approved hand controls.

(12) OML Valid only as or with a qualified co-pilot

This limitation applies to holders of a class 1 medical certificate who do not fully meet the aero-medical requirements for single-pilot operations, but are fit for multi-pilot operations. Refer to MED.B.001(d)(1).

(13) OCL Valid only as a qualified co-pilot

This limitation is an extension of the OML and are restricted to the role of co-pilot.

(14) OSL Valid only with a safety pilot and in aircraft with dual controls

This limitation applies to holders of a class 2 or a LAPL medical certificate only. The safety pilot should be made aware of the type(s) of possible incapacity that the pilot whose medical certificate has been issued with this limitation may suffer and should be prepared to take over the aircraft controls during flight. Refer to MED.B.001(d)(2).

(15) OPL Valid only without passengers

This limitation applies to holders of a class 2 or LAPL medical certificate with a medical condition that may lead to an increased level of risk to flight safety when exercising the privileges of the licence. This limitation is to be applied when this risk is not acceptable for the carriage of passengers. Refer to MED.B.001(d)(3).

(16) ORL Valid only with a safety pilot if passengers are carried and in aircraft with dual controls

This limitation applies to holders of a class 2 or LAPL medical certificate with a medical condition that may lead to an increased level of risk to flight safety when exercising the privileges of the licence. The safety pilot, if carried, should be made aware of the type(s) of possible incapacity that the pilot whose medical certificate has been issued with this limitation may suffer and should be prepared to take over the aircraft controls during flight. Refer to MED.B.001(d)(4).

(17) OAL Restricted to demonstrated aircraft type

This limitation applies to a the holder of a medical certificate who has a limb deficiency or other medical problem which had been shown by a medical flight test or flight simulator testing to be acceptable but to require a restriction to a specific class and type of aircraft.

(18) SSL Special restriction(s) as specified

This limitation may be considered when an individually specified limitation, not defined in this AMC, is appropriate to mitigate an increased level of risk to flight safety. The description of the SSL should be entered on the medical certificate or in a separate document to be carried with the medical certificate.

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

Cardiovascular risk factor assessment should take place at least once every 5 years for applicants 40 to 59 years old, and once every 2 years thereafter. A more frequent assessment of the cardiovascular risk factors may be considered when risk factors have been identified.

Applicants with an accumulation of two or more risk factors 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 should undergo a cardiological evaluation on first presentation. A fit assessment may be considered if there is no underlying pathology.

(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.

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.

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.

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.

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.

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.

A risk calculator is constructed as an equation with regression coefficients for each included risk factor, based on a statistical analysis of data from a population of a certain region to provide a crude risk estimate. A risk calculator to be used for screening of CAT pilots should be relevant for the ethnicity of the pilots being screened and should predict the 5–10-year risk for non-fatal events such as acute coronary syndromes or stroke, as well as fatal cardiac events, as both may lead to total in-flight incapacitation.

It is recommended to use a risk estimation tool that is based on populations similar to your most common target population. No risk calculator is perfect, and an assessment of advantages and disadvantages should be made when deciding on which tools should be used. For example, the most common tools that are based on European population are: SCORE 2, PROCAM, AGLA and QRISK 3.

In the risk assessment AMEs should give proper consideration to the latest published guidance of the European Society of Cardiology. At the time of the drafting, the most recent guidelines are ‘2021 ESC Guidelines on cardiovascular disease prevention in clinical practice’.

(b) Cardiovascular assessment

It is recommended that for applicants involved in single-pilot HEMS operations who have reached the age of 60, the cardiovascular assessment considers the risk level when deciding on enhanced screening investigations.

In this regard the following flow chart algorithm adapted by Simons et al. (2019) from Gray et al.(2019) is aimed at supporting AMEs and medical assessors. The classification of low, intermediate or high risk is given by the cardiovascular score being used. The enhanced screening investigations are in the realm of the consultant cardiologist.

Abbreviations used in the flowchart: CACS=Coronary Artery Calcium Score; CTCA=Computed Tomography Coronary Angiography; SPECT=Single-Positron Emission Tomography; PET=Positron Emission Tomography; CMR=Cardiac Magnetic Resonance; ICA= Invasive Coronary Angiography. [Simons et al. (2019]

(1) Spirometry

A spirometric examination is required by points MED.B.015 (b) and (c) for applicants for a class 1 medical certificate in specific situations. 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.

Obstructive sleep apnoea (OSA) screening should include an anamnestic interview and assessment of OSA risk factors such as increased BMI, and a history of cardiovascular, cerebrovascular, metabolic and ENT pathology.

(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.

SCREENING OF THE OBSTRUCTIVE SLEEP APNOEA (OSA) SYNDROME

(a) AMEs may consider the following algorithm when screening their applicants regarding the OSA syndrome:

Assessment of OSA risk may be considered at every medical examination of pilots through scores that combine history questions with physical findings such as the STOP-BANG score.

(b) AME guidance:

Indicators to initiate OSA evaluation

• History interview including at least the following:
• Daytime sleepiness (i.e. Epworth Sleepiness Scale)?
• Snoring (what does spouse/partner say?)
• Psychosocial issues due to sleepiness, heavy snoring
• Observable apnoea episodes
• Contributing factors:
  • BMI >30
    • Previous bariatric history
• Neck circumference: ≥ 40 cm
• Diagnosed arterial hypertension
• Heart troubles
  • Arrhythmia
  • Congestive heart failure
  • CHD
• Previous TIA, stroke
• Diabetes Type 2
• ENT
  • Nasal obstruction
  • Orthodontic/Retrognathia
  • Oropharyngeal examination –e.g. modified Mallampati Score or Friedman tongue position

Methodology (if indicated):

• Nocturnal oximetry
• Respiratory polygraphy
• Polysomnography in certified sleep laboratories
• Eventually evaluation of vigilance:
  • Maintenance of Wakefulness Test (MWT)
  • Multiple Sleep Latency Test (MSLT)

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.

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.

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.

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.

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.

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.

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.

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.

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.

(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.

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 secondary complication or recurrence is minimal.

(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.

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.

(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.

(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.

(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) Cognitive disorders

(i) Applicants who exhibit signs of cognitive disorders should undergo a satisfactory neuropsychiatric evaluation to assess the severity of the cognitive impairment before a fit assessment may be considered. Applicants with mild cognitive impairment may be assessed as fit with an OML limitation and regular monitoring of the cognitive decline.

(ii) For applicants above the age of 60 performing single-pilot HEMS operations, AMEs should pay particular attention to early signs of cognitive decline. A comprehensive specialist evaluation should be considered where the medical assessors received information from the personnel performing regular training and checking of these applicants in accordance with ORO.FC.230 or AMEs performing the recurrent aero-medical examination documenting a potential cognitive decline of such pilots.

(11) Assessment

The assessment should take into consideration whether 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.

(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.

(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.

(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.

(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.

(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.

(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.

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.

(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.

(5) In their examination AMEs should give proper consideration to the degenerative effects of ageing on the visual system.

(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). Where a degeneration of the visual acuity is observed, additional specialised examinations could be considered, subject to the suspected pathology;

(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 and for all cases where a comprehensive eye examination is required for applicants over the age of 45;

(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;

(4) contrast sensitivity assessment test for applicants above the age of 60; and

(5) 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.

(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.

(4) In their examination AMEs should give proper consideration to the degenerative effects of ageing on the visual system

(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) contrast sensitivity assessment test for applicants above the age of 60; and

(5) 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.

COMPARISON OF DIFFERENT READING CHARTS (APPROXIMATE FIGURES)

(a) Test distance: 40 cm

(b) Test distance: 80 cm

EYE SPECIALIST

The term ‘eye specialist’ refers to an ophthalmologist or a vision care specialist qualified in optometry and trained to recognise pathological conditions.

(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.

(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.

(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.

(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.

PURE TONE AUDIOGRAM

The pure tone audiogram may also cover the 4 000 Hz frequency for early detection of decrease in hearing.

PURE TONE AUDIOGRAM

The pure tone audiogram may also cover the 4 000 Hz frequency for early detection of decrease in hearing.

(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.

(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.

(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.