Tragedy in the Alps vs. Sleep Apnea


In the wake of last week’s troubling indications that a trained First Officer intentionally crashed an Airbus A320 in the French Alps, I couldn’t help but wonder if passengers boarding airliners are suddenly giving the crews the fisheye. Truthfully, I can’t really say I wouldn’t, but I’m no more worried about a repeat of Germanwings 9525 than I am a meteor slamming into the kitchen.

I actually have a larger concern for the families of the victims. We can do absolutely nothing to assuage their grief. Words like “closure” are just empty gestures when no words can comfort in the horror of what transpired in the Alps. They’ve been given the unbearable burden not because of a system that broke down or somehow failed them, but because of the expectation that any system or web of rules can foresee and protect against everything.

But we keep trying. Boy, do we keep trying. And an example of that has been filtering into the medical offices of aviation medical examiners during the past couple of weeks. It’s the dreaded sleep apnea rule. It’s not really a rule, but rather guidance for AMEs to give pilots their own version of the fisheye. In that context, the Germanwings crash couldn’t have come at a worse time.

In the U.S., we’re at an inflection point over the medical certification of pilots. Despite abundant evidence showing that medical certification does nothing—zero, zip, nada—to enhance safety, the FAA has steadfastly refused to eliminate the Third Class medical requirement. There’s now legislation on the table—Sen. Jim Inhofe’s Pilots Bill of Rights 2—to force the issue, which might actually have the votes to pass. Unless, of course, the body politic and freckle-necked masses think Germanwings indicates there are enough suicidal, psychotic pilots out there who are just one delayed pushback from a terminal pushover to warrant more rules. I’m hoping reason will prevail because there’s really nothing else to do.

Now on to the specifics of sleep apnea and your next medical. A short review of the history: In 2008, a Go Airlines flight between islands in Hawaii overshot its destination after both pilots dozed off. A post-incident investigation revealed that the Captain suffered from obstructive sleep apnea, but the First Officer did not, even though he fell asleep, too. The FAA’s exceptionally draconian response to this was to propose new medical procedures requiring screening for OSA and, possibly, treatment as a condition of medical issuance. The agency proposed the same requirement for controllers who are, as a group, heavier than pilots, but the FAA later admitted to AMEs that NATCA, the controllers’ labor association, push back so hard that the agency dropped the requirement for them. (Yeah, that’s how the government works sometimes. No good for me, but good for thee.)

Initially, the FAA said the screening would apply to pilots with 17-inch or larger neck sizes and a BMI of 40 or greater. Those pilots would have had their flight privileges suspended pending OSA evaluation and treatment. The FAA wanted to eventually work OSA screening down to pilots of normal weight. That would have meant a lot of pointless, expensive sleep studies, since OSA is suspected of afflicting only 4 percent of the population. The FAA got enough resistance that it substantially dialed back the OSA requirements. But the guidance is still out there and I checked with long-time senior AME Ian Blair Fries about what it means. Is there much risk that a pilot will get tangled up in this OSA mess and get grounded? There’s always some risk, but for the majority of pilots, the screening should be nothing but a minor nuisance.

Such that the FAA can speak with clarity on anything, here are two documents that show how the OSA screening should work. The first is a Rube Goldberg flow chart (PDF) and the second a list of OSA risk factors (PDF), many of which are disqualifying for non-special issuance medicals anyway.

AMEs are given latitude in how to pursue and interpret these guidelines and human nature being what it is, I wouldn’t expect consistency here. Fries told me that except in otherwise disqualifying circumstance, the AME is required to issue the medical, but must document the OSA guidance given to the patient, up to and including evaluation and treatment. And that’s where things can get expensive if a full-up sleep study needs to be done or something like CPAP is prescribed. There are alternatives and you can hear about them from Dr. Brent Blue in this podcast.

Any sensible person would see this screening for what it is: an overreach in government regulation at a time when the very foundation—whether medicals contribute to flight safety—has been proven to have no merit. It feels almost like the defiant, dying twitches of some slain beast that just won’t lie down.

And now comes this tragedy in the Alps to give new sustenance to the notion that more screening means higher safety and one that could snatch defeat from the jaws of victory with regard to the Third Class requirement. Over the weekend, I was sweeping the think-piece coverage on the Germanwings crash and came across this quote in The New York Times: “The screening process for pilots ‘really falls short for people who are involved in the public’s safety,’ said J. Reid Meloy, a forensic psychologist who consults on threat assessments for corporations and universities. The practice of screening only once a year is a particular problem, he said, because any number of life events — the breakup of a relationship, the death of a loved one or other setbacks — can affect mental functioning.”

What a surprise. A guy who makes his living doing psyche evaluations thinks there aren’t nearly enough of them, just as the American Academy of Sleep Medicine sees a nation of sleep-deprived zombies desperately in need of their tender mercies.

It’s at times like this when the sensible thing to do is to apply the kind of statistical analysis you know I’m so fond of. Call me crazy, but I have this unshakeable belief that to understand risk, you have to grasp how often what you’re trying to prevent actually happens. And measure that against the efforts you’re expending to protect yourself.

Dr. Fries puts it this way. “I can’t do this, but if I had some way of doing every possible test on you that I could and I could predict that you would have an incapacitating event during the next year, what would the risk be?” he asks. The math is simple. There are 8760 hours in a year. If you spend 100 of them in an airplane—which counts as a lot these days—the theoretical risk factor is 1.14 percent. And that both assumes that the incapacity would occur while you’re flying and/or result in an accident, both of which are stretches. The theorem proof is in the accident record. Germanwings notwithstanding, there are simply vanishingly few accidents involving medical incapacitation yet we spend millions upon millions of dollars every year trying to guard against this non-existent risk. Dr. Meloy would have us spend more.

Invert the solution for a moment and imagine that we spent those same millions trying to understand and prevent loss-of-control accidents. Could we actually dent the fatal accident rate? Quite possibly. All we know for sure—and we have the proof—is that if we didn’t expend all that money and effort on medical certification, the accident rate needle would move not one iota.

This seems lost on regulators; even ones who should know better. That same New York Times article quoted Peter Goelz, once managing director of the NTSB, as saying pilots are free to cherry-pick AMEs who might be a bit less demanding. This is an undeniable truth; we all know it. Yet even with these flaws in the system, with theoretically medically unqualified pilots slipping through, pilot medical incapacitation crashes are below the noise level, statistically. To be fair, Goelz was just observing this fact and predicting that the FAA would likely be looking into it.

None of this is an argument for having no evaluation of airline pilots, just an observation that once again, sanity is likely to fall victim to hysteria. I’m blindly hoping I’ll be wrong this time, but grimly admitting I probably won’t be.

Yay to Meet The Press

Being a news junkie, I watch the Sunday morning news shows and this week, Meet the Press led with the Germanwings story. To its credit, the show had an actual aviation professional, Embry Riddle’s Dr. Erin Bowen, to explain that no, psychological screening beyond what the airlines are now doing—airlines, not the FAA—isn’t necessary because the tools available are unlikely to identify the underlying conditions that may have afflicted Andreas Lubitz. Of course, more extensive screening and background checks might have. But is the miniscule safety gain worth all that time and money?

The topic of Lubitz’s paltry 630 hours total time came up, too, and NBC’s aviation correspondent, Tom Costello, was appalled that Lufthansa would allow such a thing. He pointed out that U.S. carriers now require a minimum of 1500 hours for FOs. I’m sure the pilots in the audience got a snicker out of that, as I did. All of us realize that the 1500-hour ATP requirement only raises the hiring barrier and has nothing to do with pilot competence.

Costello noted that the 1500-hour requirement stems from the Colgan 3407 crash in Buffalo on 2009. But that accident had less to do with pilot time and experience than pilot competence. The pilot who lost control of that airplane had failed three checkrides and might have been neither properly trained nor properly rested. A lousy pilot is a lousy pilot no matter how many hours he’s spent in the seat. The 1500-hour rule has little chance of changing that.