highlights more appalling, but sadly typical, behaviour on the part of CASA Avmed.
Dear Senator McDonald
Re: Senate inquiry into General Aviation
I write as a Designated Aviation Medical Examiner (DAME) for the Civil Aviation Safety Authority (CASA) under the Civil Aviation Safety Regulations (Cth) (CASR) 67.045. I have worked in this capacity since 2014 and am on record as being one of the busiest DAMEs in the country, currently seeing between 300 and 400 applicants annually. I am also a private (non-commercial) pilot and an aeroplane owner.
In my role, I primarily see pilots (30% non-commercial, 70% commercial), but have occasionally seen cabin crew, aviation fire-fighters, parachute instructors and air traffic controllers. Once I have seen an applicant and submitted my findings, CASA will review the application and make a determination on whether the applicant is fit to hold a medical clearance.
As a comparison, when a Licenced Aircraft Maintenance Engineer (LAME) (a “motor mechanic” for aeroplanes), completes work on an aeroplane, they sign the relevant paperwork and the aircraft is available to fly. When I, as a DAME complete the relevant paperwork on a pilot, CASA then reviews my paperwork and, never having met the pilot, may overturn my recommendation, request the applicant provide more information or issue a medical clearance.
For clarity, my role has been extended by Instrument Number CASA 26/18, dated 3 April 2018 (The Instrument), whereby I have been delegated CASA’s powers and functions for Class 2 (non-commercial) medical applications under CASR 67.165, 67.175, 67.180 and 67.195. This allows me to make all the relevant decisions, independent of CASA, with the exception that I cannot deny a medical clearance and if I believe that a pilot is unfit, I need to forward the application to CASA.
CASA does not trust DAME’s with this decision making process, as all certificates issued under The Instrument are reviewed. I have instances of my decisions being altered without my consent, for which I do not believe there is legislation providing CASA the ability to alter the decisions.
As a medical professional, it is the only area of medicine, that I am aware of, that a government regulator will review and over rule the decision of a clinician working alongside the applicant.
It is worth noting that most medical officers within CASA are not pilots and have little practical experience in aviation.
My issues with the Aviation Medicine section of CASA (AvMed) is the bureaucratic over-reach, with no consideration to cost, health risk and time of the applicant, for very little gain to the safety of air-navigation. Specialist opinion is disregarded by AvMed doctors underqualified in the relevant specialty, but “experts” in armchair bureaucracy.
I provide two examples:
Ms X
Ms X at the time (2019), was a 50yo fit and healthy female, who had held a Class 2 medical for a number of years. She is an accomplished helicopter and aeroplane pilot and had made the decision to obtain a Class 1 medical so that she could instruct. As a routine part of this examination, she was required to undertake an ECG. This was sent to an eminent aviation cardiologist who reviewed an anomaly and requested a clinical review with the patient. Following some in depth investigations and review, the cardiologist provided the opinion:
“This is an unusual finding…. but there is no evidence at this stage of any significant underlying cardiac disease. I do not believe that further investigation is indicated, and in my opinion, Miss X is fit for all activities, including flying”.
The cardiologist made the recommendation for annual testing and cardiologist review. CASA restricted both her Class 1 and 2 medical certificates, forbidding her to fly without a qualified pilot in the aircraft and shortened her medical certificates from two to one year. In the letter advising of this, CASA stated:
“Assessment of your application and specialist reports indicates that you presently fail to meet the relevant medical standard and I am satisfied that this may pose a risk to the safety of air navigation due to the risk of subtle and overt incapacitation... Your finding of rate-related left bundle branch block carries adverse prognostic significance including elevated risk of cardiac events and death”.
This decision appears to be based on one medical paper, which compares Ms X, a fit and healthy young female to a 58yo female and an 80yo male, both with significant heart disease.
CASA advised the removal of these restrictions would require angiography and electrophysiological studies. It is important to note that the AvMed doctor making this decision is not a cardiologist.
The risks from these investigations came with an approximate 1:10,000 risk of death and a 1:2,000 risk of stroke. The case was reviewed by a cardiologist who specialises in electrophysiology, who expressed that the extra testing was not warranted and the risks far outweighed any potential benefits. It was only after very significant public pressure was applied by the original cardiologist, myself and the Aircraft Owners and Pilots Association of Australia (AOPA), that CASA relented, accepted a CT Scan and provided Ms X with an unrestricted, full length (two years) medical certificate. She is now too frightened to reapply for her Class 1 medical certificate and has given up on the prospect of instructing.
Mr Y
Mr Y was a 37yo make when he first approached me for assistance. I was not his first DAME and his first application had been refused. Following a short course of ZybanTM (bupropion) to assist with smoking cessation, Mr Y experienced an episode of psychosis. Not being involved at the time, I can’t be sure of the exact details, but this disclosure and a history of drug experimentation 15-20 years earlier, appears to have triggered a cascade of events, eventually resulting in a hair drug test.
The hair drug test demonstrated the presence of methylamphetamine at 50pg/mg of hair. The report noted that the Level of Detection (LOD) was 50pg/mg of hair.
Interpretation of drug testing results are complicated and require a specialist training package from, and membership with, the Australasian Medical Review Officers Association (AMROA). There is no Australian or international standard for hair testing results, however the Society of Hair Testing (SoHT) (an international organisation) describes that LOD is the sensitivity of the relevant laboratory to consistently test a specified amount of substance. In this case, the laboratory is able to consistently detect 50pg/mg of hair, ie for every mg of hair analysed, the laboratory can detect 0.00000005mg of methylamphetamine.
However, the SoHT reports cutoffs for single use of methylamphetamine is 02.ng/mg of hair (or 200pg/mg of hair).
Mr Y’s hair test result demonstrated 50pg/mg of hair, at the lowermost level for laboratory detection, but four-fold lower than is internationally accepted as evidence of an single event of drug use. In addition, no metabolites were present. In his defence, Mr Y reports he is employed as a luxury yacht chef, that he is constantly exposed to amphetamines and other drugs in the course of his employment, but does not use any illicit substance.
The hair test for Mr Y should be reported by an AMROA member as a negative result, and CASA should have acted accordingly on that report.
Mr Y saw a psychiatrist who, recognising the result as negative, made no comment on the drug test at the time of writing a report to CASA.
CASA reviewed the drug test and the psychiatrist report and wrote to Mr Y refusing him a medical clearance.
In the letter, CASA wrote:
• “A hair test for drugs performed on 22 Aug 2018 showed a positive result for methamphetamine”
• “(Your psychiatrist) did not seem to be aware that you had a hair test that was positive to methamphetamine in the report dated 22/8/2019”
• “I have formed the view that you suffer from a problematic use of substances and have a significant psychiatric history, and that you therefore fail to meet the applicable Medical Standard. You are also an unreliable historian, having failed to disclose your medical history to CASA as well as your history of a positive hair drug test for methamphetamine to your psychiatrist”
As can be seen above, none of these assertions are correct. Based on these conclusions, Mr Y was declined a medical certificate and barred from reapplying for 12 months.
As discussed above, this all occurred prior to my involvement. He eventually approached me for assistance with a new application. At this time, I explained to CASA, in writing, my concerns with their decision and the rationale. I requested to be involved in any patient discussions held by AvMed medical staff and was declined.
Mr Y has spent the best part of $20,000 trying to obtain and maintain a medical clearance, based on a CASA opinion that is inherently incorrect.
I could provide many more examples!
As a medical practitioner, I can accept that people make mistakes, but these cases are not mistakes, these are instances where AvMed doctors have brutalised individuals, for no particular gain, except the theoretical “safety of air navigation”, which on review, was never compromised.
As much as I, and many others, enjoy acting as a pilot, we are under no illusions of the potential of a catastrophic outcome. Aviation is an inherently risky pursuit, whether in a professional or hobby capacity, but CASA needs to accept that risk should be considered against the financial and emotional burden of the decisions that have been made. There also needs to be a willingness by CASA to accept their mistakes, and to make amends to the individuals wronged.
I would be happy to present to the Rural and Regional Affairs and Transport Legislation Committee into General Aviation, if you so required.