Aviation Medicine

Mission of the Aviation Medical Association

Today, air travel is becoming increasingly popular due to the advantages of comfort, safety, and time savings. Apart from the security flights of the Turkish Armed Forces and law enforcement agencies, various activities such as passenger and cargo transportation, agricultural combat, firefighting, air taxi, air ambulance, and recreational and sports flights create density in our airspace, inevitably leading to an increase in accident or risk rates. In Turkey, while Turkish Airlines (THY) carried 218,000 passengers in 1956, the number increased tenfold to 2.2 million in 1978, including other airlines. In 1987, it reached 9 million, 35 million in 1997, and 61 million in 2006. Globally, this figure exceeds 4 billion passengers annually.


In an area involving so many people where medical support is crucial, there should be specialized medical units. While it is easy to establish general hospitals that can serve people of all ages, genders, and professions, establishing separate hospitals for aviators, employing flight doctors specialized in these matters, and conducting special medical research should not be considered unnecessary or luxurious.


Field of Interest and Focus of Aviation Medicine
Aviation medicine is a branch of medicine that deals with medical problems arising in pilots, crew, and passengers exposed to high speed, altitude, low pressure, radiation, G-forces, and movements in three planes during flights. Some common disorders seen in individuals flying as passengers or crew include hypoxia, vertigo, airsickness, decompression sickness (barotitis, bends, chokes, abdominal gas expansion), visual illusions, jet lag, disorders caused by G-forces, flight anxieties, etc. Aerospace medical specialists and flight doctors are responsible for the diagnosis and treatment of these and similar disorders. The history of flight doctors actively participating in world military aviation dates back to 1916, and in the Turkish Air Force, it goes back to 1929.


Human Factor in Flight Accidents
Airplane accidents are explained by the 4 M formula (Machine, Medium, Mission, Man). The most important M here is the human factor. Contrary to the old belief that "the one causing the plane crash is the pilot," today, errors, personal weaknesses, and inadequacies of other individuals within the system are recognized as potentially playing a primary role in accidents. Therefore, not only pilots but also other crew members, maintainers, engineers, air traffic controllers, etc., are considered elements of the human factor in flight safety. However, the most critical link in this chain is still the pilot. Within the human factor, which accounts for 70-80% of the factors in accidents, sensory illusions, physiological disorders, psychological thinking and behavioral disorders, interpersonal communication problems, etc., occupy the most significant place. As easily predictable, most of these fall within the scope of aviation medicine.


International Guidelines and Situations in Other Countries
Our country is obliged to comply with the International Civil Aviation Organization's (ICAO) 1985 pilot license directive (Section 1, Article 2.4.4), which states that pilot examinations will be conducted by doctors trained in aviation medicine.


JAR-FCL 3 (Joint Aviation Requirements-Flight Crew Licensing) from 1997 requires pilot examinations to be conducted by doctors who have completed at least a 60-hour aviation medicine course (authorized medical examiner).


In the United States, where 700,000 aviators are members of the Federal Aviation Administration (FAA) since 1929, comprehensive studies in all aspects of aviation (flight safety, certification, training, research, etc.) have been conducted. It has 300 flight doctors and 5,600 physicians authorized to conduct flight examinations (aeromedical examiners). Although most of them are within the United States, agreements have been made with doctors holding this qualification in every country. The FAA, through its affiliated Civil Aerospace Medical Institute (CAMI), requires doctors authorized to conduct flight examinations (aviation medical examiners) to undergo a 4.5-day course and take a 2.5-day refresher course every three years. Lufthansa has 16 physicians with similar authority and responsibilities; Swissair has 10. Singapore has an aviation academy. Canada, Australia, New Zealand, Switzerland, Israel, Greece, Poland, etc., have aviation medical associations and societies. (Practices in other countries can be reviewed through the internet.)


"Aviation medicine" or "aerospace medicine" is essentially a specialized field. Apart from the aeromedical examiner status, in the United States, there is advanced training in this field for 2-3 years provided by four centers (Air Force Brooks-San Antonio, Navy K. Pensacola-Florida, Army K. Fort Rucker-Alabama, and civilians Wright State University Dayton-Ohio).


Situation and Practices of Aviation Medicine in Turkey
Since World War I, flight doctors have been trained worldwide, and even during this war, Turkish pilots received support from Dr. Kauer, the flight doctor of the Germans, our allies. The first flight doctor in Turkey received training abroad (France) in 1929, and flight doctor courses have been held at the Center within the Eskişehir Air Hospital since 1948 to meet the needs of the Turkish Air Force. As a more advanced step, the Department of Aviation and Space Medicine was established at GATA in 1986, and in 1990, the world's most modern Physiological Training Center equipped with the most modern devices was put into operation in Eskişehir to simulate physiological problems encountered by aviators during flights for training purposes.


Currently, there are a few hundred flight doctors trained to meet the needs of the air, land, gendarmerie, and naval forces in Turkey. Every year, at least 30 new flight doctors join this group by attending domestic and international courses. Among them are those who participate in the working groups of AGARD, present papers at international scientific meetings, and pursue an academic career. In our country, there is only one department of aviation and space medicine within the Faculty of Medicine at GATA. In contrast, none of our universities has a department that provides education and conducts research on aviation medicine. There is one flight doctor in the Ministry of Transport, 2 in DHMİ (State Airports Authority), 2 in THY (Turkish Airlines), and 2 in THK (Turkish Aeronautical Association).


As known, ICAO and JAR, and in parallel with them, the FOM (Flight Operations Manual) prepared by THY, authorize flight doctors in pilot examinations (Section 6). However, until the end of 2004, these examinations were left to some university hospitals such as Cerrahpaşa Medical Faculty, some State Hospitals in Erzurum, Adana, and Istinye, and some private hospitals such as the German Hospital and International Hospital. Unfortunately, pilot examinations in these hospitals, which we cannot doubt their medical competence, were conducted by doctors without aviation medicine training. (Even a doctor who wants to work in a small factory is required to have a certificate stating that he has completed occupational health training.) As we prepare to enter the European Union, it was necessary for pilot examinations to be conducted as required by ICAO and JAA, and the coordination of the Ministry of Transport and the leadership of THY were required. Fortunately, as a result of the warnings of our Association, a protocol was signed between the Ministry of Transport and the Turkish Air Force in the 2003-2005 period, and 38 civil flight doctors were trained. Some of them started working in some hospitals, and the condition of their presence in pilot examinations and obtaining their signatures was imposed.


In our country, where there are more than 4,000 licensed civil pilots in the civil sector, the fact that large-budget organizations such as THY, THK, and our universities have not taken action in this regard is not only a weakness in terms of flight safety but also a deficiency in terms of scientific responsibility. In other words, in Turkish civil aviation, there is a weakness in aviation medicine and flight doctor support to keep the human factor in flight safety under control, and everyone involved in the field accepts this.


Dimensions of the Problem
The answers to the following questions may provide an opinion about the dimensions of the problem:
 

1. Are there established scientific methods for pilot selection in civil aviation? If so, how many pilot candidates have been eliminated for medical reasons to date? Also, how many trained aviators have been temporarily or permanently grounded for medical reasons in the last year? (The elimination or grounding of aviators for medical reasons is not an indicator for the satisfaction of flight doctors but is essential to ensure that unfavorable conditions that are encountered in every population are not overlooked, and necessary procedures are carried out.)
2. How are the medical fitness of those involved in sectors such as agricultural spraying, air ambulance, air taxi, and firefighting, or those flying for hobby, excitement, or sports checked, and by whom?
3. Are occasional refresher seminars, courses, and practical simulator training conducted on medical issues relevant to flight safety? Is it credible to say that the problem is solved by issuing a bulletin or distributing brochures?
4. Have procedures for intervention on health emergencies during flights been determined on the aircraft or from the ground, and is there personnel trained to perform this?
5. Are there knowledgeable and authorized individuals, or checklists, guidelines, documents, etc., determining which passengers with serious health problems should not fly or what precautions they can take?
6. Are small-scale scientific researches carried out on current medical issues related to flight safety, and are there unanswered questions in need of investigation? Is the Aviation Medicine subscribed to, and are personnel sent to medical conferences abroad, and has support been sought from relevant units of the TAF?

The answers to these questions may help assess the situation, identify a long-standing and accepted weakness, and understand what appropriate measures are.


Suggestions:
Solving this problem in the short term is an exaggerated claim, but with the belief that doing something in a field that has been neglected for a long time is a national responsibility, the Aviation Medicine Association was established on May 3, 2000. The founders are experienced individuals who have served in this field at every level for an average of 20-25 years, having been flight doctors in the Air Force, receiving training abroad, and attending courses.


The Association aims to support civil aviation in the medical issues it needs (selection, examination, treatment of aviators, health problems of passengers, etc.), organize seminars for aviators, conduct scientific research, and train flight doctors. We believe that the mission of the Association overlaps with some of the needs of Turkish civil aviation.


We believe that an advisory group should be formed with the participation of the Ministries of Health and Transport, the Turkish Air Force Command, THK, THY, and our Association, and the following studies should be conducted, some of which are urgent:
 

1. Hospitals with authorized units should be equipped with "Aeromedical Center"-like units, and there must be doctors trained in aviation medicine (authorized medical examiner) in their staff.
2. Large civil aviation organizations such as THY should be obliged to have expert personnel who can intervene or provide consultancy for aviators and passengers in routine or emergency health problems during flights.
3. Universities with Aviation High Schools (Eskişehir, Kayseri, Samsun, Isparta) should open institutes of aviation medicine or departments of aviation and space medicine, and measures encouraging specialization should be taken.
4. Large and small-scale commercial, sporting flights (glider, agricultural, firefighting, air ambulance, air taxi, police, flight school, etc.) should be inspected considering the possibility of accidents due to the health problems of the crew.
5. Most importantly, the Ministry of Transport's Civil Aviation Department should gain a guiding and controlling function at every stage (flight training, medical standards, accident investigation, space, air traffic, scientific research, etc.), covering both pre-flight and post-flight. There must be a health authority within this structure.

The neglect of informing aviators about physiological, psychological, and medical issues related to flight safety, not to mention scientific research on aviation medicine, and being outside the flow of global information is evident. We find it difficult to understand that sincere, naive, and self-sacrificing initiatives like ours have not received official responses for the time being, but we believe that everything will improve with such patient initiatives over time.


Assoc. Prof. Dr. Muzaffer Çetingüç
President of the Aviation Medicine Associatio