August 6, 2000 To Die For

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by	Kenneth A. Cubbin
	Contributor

On October 31, 1999, 217 passengers and crew lost their lives when Egypt Air 990 crashed into the sea off Nantucket Island, Mass., 40 minutes after having taken off from New York's JFK airport. With most of the wreckage now recovered from the ocean, investigators can find no evidence of mechanical failure that would warrant reconstructing the airplane. Investigation into the cause of the accident still continues. But, based on physical evidence, flight data and voice recorder information, the predominant theory remains that pilot Gamil El-Batouty -- who took the controls shortly after takeoff -- deliberately caused the Boeing 767 to dive into the sea. (The pilot's family and Egypt Air officials vehemently defend the pilot's character and insist that investigators are incorrect in their presumption.)

When aircraft manufacturers design airplanes, they incorporate failsafe and fail-operational features that make it most unlikely for any single mechanical failure to cause an accident. However, the one phenomenon that engineers find it impossible to account for is when a pilot intentionally flies his aircraft into terrain. This phenomenon is popularly referred to as "pilot suicide," although in some cases it might be more accurate to call it "murder."

Accidents like these raise troubling questions. How could such things happen, especially in the cockpit of a commercial airliner? How could a pilot who commits such a crime have remained functional on a day-to-day basis before the tragedy? How could such an obviously troubled pilot have avoided detection by family and friends? Why couldn't other crewmembers have stopped the pilot from carrying out his destructive act?

Could they have been stopped?

In 1997, a SilkAir Boeing 737-700 crashed into the Musi River in Indonesia, killing 104 people. Investigators concluded that the most probable cause of this accident was deliberate, controlled flight into terrain by the captain who -- in an effort to confuse future investigation into the accident -- allegedly pulled cockpit voice recorder and flight recorder circuit breakers while returning from a visit to the rest room. If this scenario is true, then the captain's actions constitute premeditated murder. Apparently, the captain had recently been demoted from instructor and many other pilots who had flown with him had informally complained of his non-standard operation. Therefore, there was some evidence of aberrant behavior by this pilot prior to this accident that may have been a clue as to his state of mind.

In 1994, a Royal Air Maroc ATR-42-300 jet plunged into the ground ten minutes after takeoff from Agadir killing all 44 people on board. Investigators concluded that the captain had deliberately steered the plane into the ground. (The Moroccan Pilots Association disputes this claim.)

In 1982, a Japan Airlines (JAL) DC-8 crashed into Tokyo Bay while on approach to Haneda Airport in Japan, killing 24 and injuring 141. The captain allegedly pushed the nose down prematurely and pulled the inboard engines into reverse while on approach to the airport. Despite attempts by the first officer and flight engineer to rectify the perilous flight path, the captain was successful in his efforts to terminate the flight prematurely. After exhaustive investigation of this accident, the captain was placed into a psychiatric institution. Sources at JAL who knew this captain personally informed accident investigators that it was general knowledge the captain's behavior had been erratic before the accident. After the accident, there were accusations that JAL's management had been aware of the captain's mental instability but had failed to relieve him of flight duty. However, Japanese authorities ultimately concluded that both of these accusations were unfounded.

In several of the above examples, a pattern of aberrant behavior had been demonstrated by the pilots who eventually took their own life and the lives of others.

Psychological testing of pilots

According to American Psychological Association (APA) databases, a number of papers have been written on the subject of pilot suicide in general aviation. For example, a 1994 paper by Timothy J. Ungs titled "Suicide by Use of Aircraft in the United States, 1979-1989" states that the NTSB reported nine fatal accidents attributed to pilot suicide during the 1979-1989 period. NTSB investigations identified evidence of important adverse psychological factors in most of the pilots, including depression or negative life events.

In 1998, Anthony S. Cullen reported in his paper titled "Aviation Suicide: A Review of General Aviation Accidents in the U.K., 1970-96" that out of 415 general aviation accidents, three definite cases of pilot suicide and possibly another seven occurred in the United Kingdom. Again, the pilots' previous psychiatric problems, familial instability and alcohol misuse were identified as causal factors.

In Germany, Bernhard Maeulen reported in his 1993 paper titled "An Aeronautical Suicide Attempt -- Suicide and Self-Destructive Behavior in Aviation" that:

Investigators concluded that precursors to these accidents included pilot depression, alcoholism and family problems.

Although these papers all refer to general aviation, their conclusions appear to concur that the offending pilots had a history of previous psychiatric or domestic problems and/or alcohol abuse. It would be logical to assume that similar problems exist in the lives of airline pilots. What can be done to ensure that such tragic events do not occur again in commercial aviation?

Three vs. two

At first look, it would appear logical that three crewmembers in the cockpit stand a better chance of ensuring such events will not occur. For example, had three crewmembers been on the flight deck of the SilkAir B-737, the captain might have found it much more difficult to surreptitiously pull circuit breakers when returning to the cockpit from an in-flight visit to the rest room. If he had not been able to throw this curve ball to future investigators, he might have aborted his plan to crash his airplane.

Conversely, the JAL DC-8 accident in 1982 would suggest that three persons are no more effective than two at preventing pilot suicide, since the first officer and flight engineer were unable to prevent the captain from his dire actions. Such a conclusion might be premature, however, because until approximately 15 years ago, the patriarchal society that has existed in Japan for centuries dictated that subordinate males revere and never question senior males. Therefore, one can only wonder how vigorously the first officer and flight engineer fought with the captain for control of the aircraft. Of course, even if the first officer and flight engineer fought the captain with all means at their disposal, the aircraft was at low altitude with two engines in reverse, so perhaps it was a case of "too little, too late."

After Cockpit Resource Management (CRM) programs were introduced into Japanese airlines in the mid-80s, the status quo of blind hierarchical obedience began to change. In addition, contemporary youths in Japan's general population are questioning the validity of "the old way" and are rebelling in various ways against their elders. As a result, if the same circumstances were to occur today, it is probable that a Japanese captain would be more vigorously restrained by the other crewmembers. Still, as mentioned previously, if the aircraft were low and on approach, any efforts to recover the aircraft might still be unsuccessful.

During my flight engineer training experience over the last 20 years, I have conducted episodes in the simulator where the captain was instructed to act as though he had become incapacitated. The fastest method of restraining the captain under such conditions, I discovered, was for the flight engineer to grasp and pull back on the captain's shoulder harness. This was entirely adequate for subtle or non-violent incapacitation as it kept the captain from interfering with the first officer's control of the aircraft. However, if the captain were physically resisting restraint -- as he might if he were intent on killing himself and all on board -- it might be necessary for the flight engineer to use force to ensure the first officer could recover the safe operation of the airplane. How much force might be necessary?

According to one report of the SilkAir crash, the sound of what is thought to be the first officer being struck by a heavy object is heard on the CVR shortly before the aircraft impacted the ground. If a flight engineer had been on board, would he or she have used a similar measure of force to restrain the captain in time for recovery? Can a rational crewmember come to the conclusion that the captain must be violently stopped from his criminal intentions in time? I think it highly unlikely.

So although it might seem logical that having three flight crewmembers aboard all flight decks might prevent such occurrences, this is by no means certain. Three crewmembers might still be duped by the covert action of one -- and two crewmembers might be unable, or unwilling, to use sufficient force to restrain the third in time to recover safe operation of the airplane.

Who's at risk?

Let me say up front that I have no psychological or clinical psychiatric expertise. But an article titled "The Neurobiology of Depression" published in the June 1998 issue of Scientific American presents some opinions that I find quite interesting. At the time the article was published, its author Charles B. Nemeroff was professor and chairman of the Department of Psychiatry and Behavioral Sciences at the Emory University School of Medicine.

In his article, Professor Nemeroff describes the symptoms of depression as being quite different from "the blues" that everyone feels at one time or another, including grief from bereavement. He states that depression can include a sense of overwhelming sadness, guilt, and a sense of self-worthlessness. A person suffering from depression may lose appetite and have trouble sleeping -- or conversely, want to eat and sleep constantly. Such people can be preoccupied with suicide and have difficulty thinking clearly, remembering, or taking pleasure in anything.

How can someone suffer from such debilitating effects and yet remain functional? Eva Winer, a spokesperson for the APA, explained that in her career as a testing officer in a psychiatric hospital, she had seen "many deep-seated, practically asymptomatic cases of 'smiling' or 'larvae' depression that didn't impair daily functioning and easily went undetected for a long time." Therefore, presumably, a person can be severely depressed, yet hide it from his or her peers.

Professor Nemeroff suggests "that 5 to 12 percent of men and 10 to 20 percent of women in the U.S. will suffer from a major depressive episode at some time in their life. Roughly half of these individuals will become depressed more than once, and up to 10 percent (about 1.0 to 1.5 percent of Americans) will experience manic phases in addition to depressive ones, a condition known as manic-depressive illness or bipolar disorder… As many as 15 percent of those who suffer from depression or bipolar disorder commit suicide each year."

In what may be a very disturbing statistic in relation to pilot suicide, Professor Nemeroff contends that "many people who kill themselves do so in a way that allows another diagnosis to be listed on the death certificate, so that families can receive insurance benefits or avoid embarrassment."

The FAA as "Doctor No"

A deficiency in serotonin in the brain stem can result in the affected person suffering ailments such as severe and chronic depression. This subgroup of depression sufferers will find no relief unless their condition is treated with medication. Antidepressants such as Prozac have been very successful in treating depression.

However, antidepressant medication is currently not approved by the FAA, and a pilot who is prescribed such medication will have his or her medical revoked. For transitory depressions, the pilot who chooses to take antidepressants can have his or her medical restored after the he or she has discontinued medication for 60 to 90 days and the prescribing doctor confirms in writing that the pilot's original condition is no longer evident.

The makers of Prozac, Ely Lilly and Company, state that the drug's benefits may not become apparent until one to four weeks after beginning the medication. It also recommends that antidepressant medication be taken for six to 12 months to monitor its success. Approximately 17 million Americans have been treated with Prozac and the drug has been proven safe and effective over the last ten years. Side effects can include nausea, insomnia, drowsiness, anxiety, nervousness, weakness, loss of appetite, tremors, dry mouth, sweating, decreased libido, impotence or yawning. These side effects tend to go away after several weeks of medication.

Presumably, since usage of Prozac and other antidepressants is so widespread, other professionals in highly demanding and responsible positions continue to function while taking the drug. Doctors, school bus drivers and police officers are just a few job classifications that come to mind. If a cardiac surgeon is taking Prozac, does he or she suffer the same scrutiny by his or her regulating authorities? I don't recall reading any reports of doctors who have had their license revoked simply because they were taking antidepressants.

However, since the FAA will not allow a pilot to fly while on antidepressant medication and for a period of up to three months after cessation, if a pilot elects to be treated in this manner, he or she could be out of work for well over a year. In adopting this attitude toward a treatment that has been proven safe over the last ten years, the FAA tacitly forces a professional pilot with severe depression to make an agonizing choice: give up his career, or continue to fly without treatment.

FAR Part 67.107 states that a pilot can have no established medical history or clinical diagnosis of psychosis (delusions, hallucinations, etc.), personality disorder, neurosis, bipolar disorder or other mental condition. This is explicit and precludes a pilot any hope of getting treatment for depression without having his or her medical revoked. A group of online AMEs, Virtual Flight Surgeons (http://www.aviationmedicine.com), point out that the primary medical responsibility of the FAA is to gauge whether a pilot's medical condition is compatible with safe flight. Medication and its effect on treatment is secondary, and the FAA may also ground pilots who suffer from side effects of medication.

Perception vs. reality

Unfortunately, as an agency that depends on Congress for its budget, the FAA has to be concerned not only with actual safety issues, but also with the perception of the travelling public. In this regard, the powers-that-be at FAA Headquarters seem to believe that the travelling public would never accept the idea of having their flight piloted by a person taking antidepressant medication.

The truth, however, is that by disqualifying pilots who are prescribed antidepressant medication, the FAA has created a situation that is potentially much more serious: The traveling public may have their aircraft piloted by a person who is severely depressed but masking his or her symptoms -- or a person who is taking medication on the sly -- in order to keep his or her job. Under such circumstances, which flight will prove to be the last straw for the pilot who can see no light at the end of a tunnel?

Despite becoming more sophisticated in terms of mental disorders and accepted treatment, there is still a stigma assigned to those people who receive such treatment by the general population. Any number of stand-up comics and comedians routinely refer to those who take Prozac and other antidepressants in a derogatory manner. A person who has a serotonin deficiency has a similar need for medication in order to remain functional as a diabetic who needs insulin. However, one never hears a comedy routine belittling those who regularly take insulin shots. Apparently, one chemical deficiency is socially acceptable, and the other is the butt of jokes. Ironically, the FAA will now consider reissuing a third-class pilot's license on a case-to-case basis for those people who require insulin to control diabetes. Several other medications used to treat other potentially debilitating ailments, such as migraine headaches and Parkinson's Disease, also have FAA approval.

As a result of the present situation, even if a pilot is aware that antidepressants might alleviate his or her depression, he or she might elect to "tough it out" in order to remain employed and provide an income for his or her family. To make matters worse, a pilot may be severely depressed but not recognize the insidious nature of his or her condition; in this case, seeking medical attention might not even occur to him or her.

Between a rock and a hard place

It is the very nature of flying single-pilot aircraft that no other person can assist while the aircraft is in the air. The pilot is the person who must make the decision, good or bad. Therefore, because a pilot spends the formative years of his or her flying career as a sole pilot-in-command, he or she develops a strong sense of independence and self-reliance. This independent streak might prevent a pilot from seeking help if he or she has a problem that seems insurmountable. Alternatively, he or she may refuse to acknowledge that a problem really exists.

For an airline pilot, flying changes from an enjoyable hobby to a career. Professional pilots are expected to conduct themselves with propriety and diligence. Every year, a physical examination is conducted to assure authorities that each pilot is physically and mentally capable of continuing to fly.

Most airline pilots marry, have children, and assume all the financial burdens typical of modern adults. As a consequence, the pressure of needing to continue to work to support a family might restrict a professional pilot from taking time off to address his or her problems.

Another factor that may cause airline pilots to hide or ignore their problems and avoid medical help is the complex and sometimes adversarial relationship that exists between pilots, the FAA and airline management. Airline managers ask pilots to confide their innermost problems, while simultaneously threatening to take away their livelihood. The FAA is even more intolerant, with the criteria for losing a pilot's medical mostly spelled out in the black-and-white clauses of FAR Part 67.

To be fair to airline management and the FAA, they have to impose strict control over pilots' fitness. It would be irresponsible of them not to remove pilots with severe mental problems or alcohol abuse from the flight line. However, the knowledge that a pilot can be relieved of flight duty and possibly dismissed undoubtedly prevents many pilots from seeking medical assistance, and discourages crewmembers from reporting misdemeanors committed by their peers. Who wants to be responsible for a pilot's family suffering because of a loss of income? What pilot would voluntarily confess to a condition that would mean imminent removal from flight duty unless forced to do so?

In my airline career, I have known of only two crewmembers who ultimately lost their job because of alcohol abuse. Both of these pilots were commonly known to have severe drinking problems, but none of their peers complained to management nor refused to fly with them -- probably for the reason stated above. Ultimately, both of the pilots self-destructed: One embarrassed himself and the airline by his behavior while deadheading and the other was arrested for insobriety while on a layover. Both were given an opportunity by the airline involved to seek help for their problem -- however, both of the pilots resigned.

Only one pilot, with whom I have been acquainted, was reported to airline management by his peers for irrational behavior. When his manager called the accused pilot onto the mat, he was faced with the reports by his compatriots -- as a result, he resigned. Whether the pilot resigned over a sense of guilt or embarrassment, or whether he just couldn't imagine continuing to work with other pilots who had complained of his behavior, I will never know. To this day, there are many pilots and flight engineers -- myself included -- who believe that personality clashes with a few of this pilot's peers brought about complaints to airline management that were both unwarranted and exaggerated. Depending on your point of view, either a mentally unstable pilot was rightfully removed from flight duty, or an innocent-but-eccentric individual was vilified by a few treacherous fellow crewmembers.

Alcohol abuse is treatable and a full recovery to normal sobriety is possible. However, for more insidious mental disorders such as depression due to chemical imbalances in the brain, a pilot may have no hope of maintaining his or her employment if he or she seeks help. That person is stuck between a rock and a hard place.

AVweb's survey results

A recent informal survey conducted by AVweb asked and received responses for the following three questions:

1. Have you ever had a medical condition for which you chose not to seek treatment for fear that disclosure might jeopardize your flying? (567 responses)
   • YES -- 46%
   • NO -- 54%
2. Have you ever had a medical condition for which you sought medical treatment, but then failed to disclose it on your FAA medical application for fear that disclosure might jeopardize your flying? (563 responses)
   • YES -- 32%
   • NO -- 68%
3. Do you take medication about which you have not told the FAA? (561 responses)
   • YES -- 21%
   • NO -- 79%

The responses to these questions clearly indicate that a significant number of pilots would rather self-medicate or try and work through their problems without professional medical assistance, rather than risk losing their medical.

These statistics may actually understate the problem. Feedback to AVweb on the survey questions indicates that a number of pilots did not respond to the survey for fear the FAA would somehow find out their identity. Therefore, the statistics above may actually underestimate the number of pilots who are reticent to seek medical treatment for fear of inciting the wrath of the FAA.

Aggravating factors

As a crewmember on long-haul international flights, it's my opinion that duty cycle patterns that cause a pilot to be isolated from his or her family and home life for extended periods of time can only exacerbate depression. We all know what happens: The day after you walk out the door to go to work, your child has an asthma attack and has to be hospitalized or the plumbing in the attic leaks and floods the house. Whatever the catastrophe, it's sure to occur when you are away from home. A depressed pilot may feel responsible for these family crises and blame him or herself.

Cumulative fatigue caused by chronic circadian rhythm disruption and heavy workloads imposed by the airline duty roster can weigh heavily on any pilot's shoulders. If a depressed pilot is already finding it difficult to sleep, then the weight added to his or her fatigue by flying the line may be enough to push him or her over the edge. To top it off, a depressed pilot's feeling of being unable to seek medical help can only serve to deepen his or her sense of hopelessness.

Each of these influencing factors can be alleviated to some degree if airline management and pilots' unions work together. However, if the FAA were to change its policy and allow pilots to resume normal functionality with the use of safe and effective drugs, then the potential of pilot suicide may be alleviated.

No easy answers

What a kettle of worms! Statistically many pilots will likely suffer from depression at some point in their career, but may not seek treatment out of fear of losing their job. Experts say that it is quite possible for a pilot to mask the seriousness of his or her condition. Even if a pilot recognizes his or her condition and desires to seek medical assistance, treatments such as Prozac may not be available without throwing away his or her career. If the airline or the FAA discovers that a pilot has sought medical assistance for depression and/or was prescribed medication, then there is a good possibility that the pilot will be suspended from flight duty. The FAA is charged with maintaining aviation safety, but by its lack of latitude in allowing a pilot to fly on antidepressants, it is arguably eroding safety rather than enhancing it. The FAA says it's looking at the problem, but in reality the agency is probably scared to death of the political repercussions if it were to relax its absolute prohibition on psychotropic medications

Airline management, having become more aware that such things as pilot suicide exist in our modern world, have to tighten their scrutiny of pilots' mental fitness while maintaining an empathetic attitude towards the affected pilots' careers. Airline unions would likely resist any exhaustive psychological testing of their members each year as such tests could be used to justify airline managers who selectively dismiss troublesome employees. However, a balance of what is good for the pilots and what is good for the safety of all who fly with them must be met. Airline management can act to alleviate the fatigue factor caused by long duty-days and long patterns, and should do so immediately.

One airline with which I am acquainted includes a psychological test as part of a crewmember's annual physical. However, the test is hardly comprehensive -- the questions asked by the medical examiner are general in nature and easily deflected by the crewmember being examined. As far as this test is concerned, it seems as if the airline is content with making a token effort at ensuring each of its crewmembers is mentally fit. Having said that, at least it is making some effort to assess crewmembers' mental alacrity and well-being.

The sad truth is that it may be up to us -- pilots and flight engineers -- to bring other crewmembers' aberrant behavior to the attention of airline management. As much as we all hate to tattle on our peers, such action might be necessary in the interest of safety. But what constitutes aberrant behavior? Should a pilot be reported because he or she is depressed over an impending divorce? How do you protect an eccentric individual from being wrongfully accused? Who is to set these criteria? I, for one, would be reluctant to tread this path unless a pilot had blatantly put his or her crew and passengers in imminent danger ... but by then, it may be too late.

Even though evidence exists that some pilots have functioned normally on a day-to-day basis while undergoing severe depression, it seems highly unlikely to me that someone, somewhere, was not privy to the affected person's mental state. In each of the airline pilot suicide cases mentioned at the beginning of this article, the pilot's family refused -- out of a sense of loyalty, or out of denial -- to believe their loved one would commit such an act. However, if members of the pilot's family were truly honest with themselves, maybe they would recall evidence of their loved one's illness. Those closest to the depressed pilot are the most likely to identify the problem. However, family members and close friends are also the least likely to turn the pilot in (ex-wives and ex-husbands excepted).

There are no easy answers. At the very least, I would suggest that a cooperative study be conducted by pilot unions, airlines, the FAA and appropriate medical authorities to determine what can be done to assist pilots who suffer from serious depression without jeopardizing their employment. Anecdotal and clinical evidence exists that prove a person can return to normal function after being treated with antidepressants and waiting for any associated side effects of the drugs to dissipate. In the hectic pace of modern life where more and more people are becoming disassociated from each other and there never seems to be enough hours in the day to accomplish all that we need to do, the prevalence of depression is likely to increase. Somehow, we must all work together to ensure that those who need help for depression can get it without jeopardizing their career.

The wheels turn slowly at the FAA, but it is high time that pilots were reclassified as normal human beings who suffer from everyday, treatable ailments that can be controlled effectively by the use of medication. The alternative could be murder.