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Director of Aviation Safety, Mark Skidmore
Colour Vision Deficiency (CVD)
Recent Developments in Aviation Medicine
Aviation Medicine Regulatory Process – Way Forward
Director of Aviation Safety, Mark Skidmore
Aviation Medical Society of Victoria – 28 February 2015
- Thank you David for your generous introduction. It’s a privilege to be talking to such a distinguish gathering today.
- By way of introduction I am a former F-111 pilot with the RAAF, and more recently had the amazing opportunity to pilot the RAAF Museum's Bristol Boxkite replica at Point Cook on its maiden flight. So to speak, I have flown one of the fastest and one of the slowest planes that have been in the RAAF’s inventory – in that respect, I’ve been exposed to extreme conditions at both ends of the spectrum and appreciate what it takes in the world of aviation to recognise ‘safety’ as the number one priority.
- I understand that Australia has the highest number of pilots per head of population of any country in the world. Every pilot needs to go through a periodic medical check; hence, the importance of aviation medical practitioners is not to be understated.
- CASA’s core services in relation to Aviation Medicine include medical certificate processing, appointment and management of Designated Aviation Medical Examiners (DAMEs), DAME training and the development of aviation medical standards through national and international workshops. Processing medical certificate applications represents over 80 per cent of all AvMed activities.
- Notwithstanding the noise and the complaints we hear from time to time, CASA’s aviation medicine Branch is very proactive in its approach with the main purpose of keeping people flying where possible. As a result of considerable advances in medicine, we are now seeing pilots continuing successful careers with conditions that not all that long ago would have seen them unable to hold a medical certificate.
- The therapeutic advances and ageing of our population are enabling an ever greater number of pilots to retain their medicals into their 70’s 80’s and 90’s. Once there was a simple list of conditions, which largely described the end of a flying career. No more many applicants now present with a complicated regime of treatment which permits an active lifestyle to continue. The assessment of risk in the aviation setting has become a lot more complex, and new paradigms constantly need to be developed.
- Let me provide some examples; Cancer treatments are increasingly keeping the underlying condition in remission. While some have significant side-effects, newer agents are enabling pilots to return to work productively: something never possible only a few years ago.
- Now we allow pilots to fly when using anti-depressants. Australia was the first jurisdiction to allow this. We allow pilots to fly even if they are in remission and using only a single medication.
- Our protocols related to using insulin have been well appreciated worldwide. We continue to review and develop the parameters. Pilots can now be assessed for a return to flying only 6 weeks after stenting when certain conditions are met, instead of the statutory 6 months.
- As most of you are aware, the Government has set a clear agenda for CASA in 2015 and the years to follow through its response to the Aviation Safety Regulation Review (ASRR), which was released late in 2014. I am glad the Government’s response to the Review has coincided with the commencement of my tenure as the Director of Aviation Safety, as this provides a clear basis for planning, action and achievement.
- Aviation medical concerns were amongst the more contentious issues raised in submissions to the ASRR and continue to be the subject of industry stakeholder comment. We are aware of a range of concerns raised by some members of the aviation community in the Report in relation to administration and decision making processes with respect to the issuing of aviation medical certificates.
- In response to the ASRR, CASA has already identified a range of administrative measures to improve turnaround in the processing of certificates.
- In relation to more contentious medical conditions, the Government has asked that CASA ensure its processes are as transparent as possible to the applicant, including the supporting reasons for its decisions to grant or not grant a medical certificate or place conditions on licences. It is acknowledged that different specialists can reach a different view on particularly complex cases but ultimately CASA has to make its decision based on aviation safety grounds.
- Moreover the Government has asked that CASA undertake a review of its aviation medical Branch to establish whether a more effective and efficient system might be put in place without adversely impacting on safety.
- Although the Aviation Medicine (AvMed) capability in CASA has achieved a range of significant improvements in performance and outcomes over the past three years, CASA recognises the need to improve its service delivery and to ensure that its decision-making processes are transparent and evidence-based.
- As with other similar regulators, CASA is having difficulty in recruiting and retaining medical staff and a continued high level of CASA resources are tied up in aviation medical case reviews, complaints and appeals. These and other competing work pressures are contributing to a significant backlog of cases for medical review.
- However, on a positive note let me tell you that CASA has already commenced a process to permit approved DAMEs to issue and renew Class 2 medical certificates. A post implementation review of this process will be conducted in the second half of 2015.
- The results of the post implementation review will be considered and assessed to inform future consideration of a detailed examination of issues involved with the potential ability for DAME’s to renew medical certificates for classes 1 and 3 as identified in the ASRR’s recommendation.
- Further, we have commenced a full review of our AvMed capability to ensure that the delivery of its functions are effective and efficient, and fully aligns with CASA’s obligations under the Civil Aviation Act, the expectations of Government and the needs of medical certificate applicants. The review will include looking at various options to improve service delivery and the options for obtaining timely expert advice on complex matters. The review will be completed by the second half of the year.
- Let me provide a bit more detail on this review for your information. During this review, we will consider, amongst other things:
- ongoing issues experienced with the recruitment and retention of suitably qualified and experienced aviation medicine medical practitioners,
- the strategic approach to aviation medicine policy standards and clinical practice development, and
- options for how the organisation can optimally deliver aviation medicine services into the future.
- The review is planning to engage with stakeholders (applicants, broader industry and other key stakeholders) in the coming months to collate feedback on the business improvements currently being made to AvMed. Active engagement in the review is encouraged to ensure that all contributions are captured in improving the delivery of this important function.
- CASA’s Aviation Medicine Branch is seen as one of the gateways that interact with the significant number in the aviation industry. In 2014, CASA received 25,855 medical applications, issued 25,125 medical certificates and refused 102 applications. The remaining 628 applications were still in progress or not issued (due to non-payment) or withdrawn by the applicant.
- Between July and December 2014, 13 complaints relating to the Aviation Medicine Branch were received. Of these 13 complaints, 8 complaints were related to CASA decisions.
- We understand that, like other regulatory authorities in Australia, and not unlike aviation safety regulators throughout the world, CASA is no stranger to criticism, complaints, and other expressions of dissatisfaction about the things we do and the way we do them. We recognise that this as an inevitable feature of the regulatory landscape. Where such criticism is warranted, however, you may be assured it is my intention to see that its causes are identified and addressed as quickly and effectively as possible.
- To that end, I believe both the regulator and the regulated community need to build a closer working relationship based on a mutual interest in the achievement of shared safety outcomes. That relationship must be built on respect and trust. CASA is open and committed to an appropriate ‘safety partnership’ with the aviation community with a view of achieving better safety outcomes. To achieve this we need an effective and meaningful engagement and communication with all interested parties, both at a strategic and working level. This is one area to which I intend to devote time and energy.
- Improving relations with the aviation community does not mean agreeing to the whims and fancies of some individuals, who purposely drive their own agendas with a view to advancing their personal, and sometimes narrow, views about the direction in which aviation safety should move. Not everyone will get everything they want, and it will not always be possible to reach consensus. I will however make sure that we listen, that different viewpoints from within CASA, and across the industry and the wider aviation community, are aired, and that our response is always in best interests of aviation safety.
Colour Vision Deficiency (CVD)
- My speech won’t be complete if I don’t touch on the delicate subject of CVD. Australia does differ from other countries in relation to the requirements surrounding CVD. Australia is more flexible in allowing applicants to sit multiple sequential tests for CVD where they record a fail and can issue a medical certificate if at any stage any of the three-level tests are passed. Most overseas regulators do not allow this level of flexibility. For example the UK does not allow for any second chances if an applicant fails their only test, the CAD test. They do not receive a Class 1 medical certificate.
- In mid-2014, it was determined that the handling of pilots with CVD had not been in strict accordance with Civil Aviation Safety Regulation Part 67 (Medical). CASA advised industry of its new process relating to the regulations in June 2014. This was done to provide industry with information to assist in understanding their obligations in relation to the regulations. The new processes related to new applicants only and there were no impacts on existing pilots. In response to some of the correspondence received, CASA updated the CVD information on its website.
- In February 2015, CASA had 134 Class 1 medical certificate holders and 252 Class 2 medical certificate holders who have failed the Ishihara test.
- CASA is considering the Colour Assessment and Diagnosis (CAD) test as a third-level test. CASA has determined the CAD test is suitable as an aviation specific test for detecting CVD. It is used by the UK and is also available in the US as an option for testing for CVD. CAD provides for colour and diagnostic testing, which can determine the degree of colour deficiency, which is something that is currently not able to be determined by the Ishihara or Farnsworth tests.
- Whilst I am not considering further changes to policy or standards at this time, any proposed changes will be consulted through the SCC Medical sub-committee. Pilots with existing CVD restrictions will require no other tests related to CVD, unless other medical reasons determine a need to do so.
Recent Developments in Aviation Medicine
- Our new Medical Record System (MRS) is planned to go live in April 2015. This new single system is a major upgrade permitting online application and processing. The MRS is currently comprised of four separate systems that loosely operate together to provide AvMed with the administrative functionality they require.
- There are components of the current MRS that are nearly 20 years old and are no longer supported by a vendor. The current system also relies on a number of manual processes such as document scanning, payment receipt verification and mailing of specialist referrals.
- In the new system, the pilots and air traffic controllers will be able to fill out an online medical questionnaire and make payments via the new system. The DAMEs, Designated Aviation Ophthalmologists and Certified Optometrists will also be able to carry out examinations using the new system. This will include providing them appropriate access to an applicant’s historical information gathered through previous medical exams.
- In cases where the applicant meets the right criteria, the DAME’s will then be able to provide their medical certificate on completion of the exam. Where DAME’s aren’t able to issue a medical certificate, those cases will be submitted to AvMed for assessment and in some cases will be referred for intensive case management by CASA’s doctors. To help introduction of the new system, we will deliver face-to-face training to pilots and DAMEs across Australia and will also publish training videos and material on the CASA internet site.
- In addition to the dedicated AvMed help line we already have in place, we intend to further improve our lines of communication with the applicants and DAMEs by using emails and SMS messaging for reminders and prompts.
- Further, we are also working to establish DAME communications and chat facility to replace letters for progressing assessments. Publishing of further Clinical Practice Guidelines also will continue. In addition we have started work on improving information to pilots and controllers on medical matters. You will also notice that the website for looking up a DAME/ DAO has been significantly upgraded.
- Dr Michael Drane, Acting Principal Medical Officer, who is present with us will provide more details on recent developments of AvMed in his presentation.
- We are not perfect, we can all learn important and lasting lessons from our past and move forward. As I have said, we are in the processing of addressing some issues in ways that we can improve our service delivery with a view to maintaining and improving safety.
- I thank you for the opportunity to make the keynote address, and I am happy to take questions.