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CASA Avmed – In my opinion, a biased, intellectually dishonest regulator

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CASA Avmed – In my opinion, a biased, intellectually dishonest regulator

Old 9th Dec 2018, 21:23
  #81 (permalink)  
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If a loaded gun is held to your head, and someone intervenes so that your brains aren’t blown out, does that intervention “involve the blood supply to the brain”? I suppose it does “in the broader sense” ...

The way it was explained to me by the specialists was that the purpose of the intervention, and the way in which the intervention was carried out, was to avoid interference with the blood supply to the brain. That makes pretty good sense to me.

The advice to me was that if there had been no intervention or the intervention had gone wrong, lots of bad things could have happened. Fortunately, the advice to me was the intervention on 23 August was a success, confirmed by a subsequent dynamic CTA on 9 November and intravenous DSA on 30 November.

But I get it that even amateurs like you know better.
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Old 9th Dec 2018, 21:40
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the purpose of the intervention, and the way in which the intervention was carried out, was to avoid interference with the blood supply to the brain
Which strongly suggests to me that this vascular malformation involved the blood supply to the brain.

If someone with medical training wants to contradict that, I am happy to be corrected.
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Old 9th Dec 2018, 21:50
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I think the crux of the matter is the belief Nowluke and AVMED have of
The opinion of a "specialist" is the lowest evidentiary weight in clinical decision making.
. Having worked in the medical industry and having friends and family who are in the medical profession this statement I think would be insulting. I know of two people who are considered to be in the top 10 in the world in their field, the data input to any "gold standard clinical trials" would consist partly of their work. They would be the best people to understand any nuances born out of any clinical trials that may have been conducted, rather than some statistical analyst or bureaucratic medical officer. Yet the arrogance of AVMED and Nowluke suggest that these people know nothing of the outcomes of the procedures they perform!
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Old 9th Dec 2018, 22:33
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We are talking here about an ADMINISTRATIVE decision. The point of Clinton’s complaint is that the ADMINISTRATIVE decision is flawed on many levels. This is not a forum for pissing competitions by doctors.

The logical outcomes of Avmeds deliberations Should have been;

1. yes

2. no

3. yes, in twelve months, provided.....

instead he got “let’s put off any decision at all for twelve months or perhaps longer and we still may decide not to issue for unspecified reasons”.
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Old 10th Dec 2018, 08:53
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Thanks Nowluke. Interesting (and I assume informed) posts.
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Old 10th Dec 2018, 10:24
  #86 (permalink)  
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My 2 cents’ worth is that nowluke seems to me to have provided an accurate and expert description of the current reasoning for the current approach. As posted and noted earlier:
The opinion of a "specialist" is the lowest evidentiary weight in clinical decision making.
That is a manifestation of an important concept that was new to me: I’ve learnt that there’s a willie-wagging hierarchy in medicine. Apparently, there’s a causal link between a person’s compliance or otherwise with a medical standard and the recognised comparative length, in the medical hierarchy, of the willie of a medical professional expressing an opinion about the person’s compliance. Go figure.

I have an appointment with someone whom, I’m advised, has the largest willie in the hierarchy. I’m looking forward to getting the person’s opinion and the reasons for it.
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Old 16th Dec 2018, 07:15
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Update: Fees incurred so far

Fees incurred in battling CASA so far: $6,522.00.

On current advice, if I have to go to a ‘full blown’ AAT hearing I wouldn’t expect too much change out of ten times that.

No one on an average income or less could afford to do this.
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Old 17th Dec 2018, 08:21
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There's one small problem for those excusing CASA's appeal to "prudent caution": one of CASA's own published Aviation Medicine case studies.
It's the one describing "Jim's" stroke at age 76, which finally grounds him (just in case this, my first PPRuNe post, does not permit URLs, and any of you need to search).

In this case study, CASA describes grounding a pilot who has a stroke, at the age of 76. This means, by CASA's own documentation, CASA continued to renew Jim's Class 1 medical certificate (with conditions) when Jim was aged 75, and diagnosed with Type 2 diabetes, and known to have high cholesterol and high blood pressure.
Here are some "medical" stats:
1. The absolute annual risk of one quite severe medical condition (mild death, with recurring symptoms) for the average 75 year old Australian male is about 4%. Just go to the ABS and take a look at the life tables to confirm. 5% annual chance of death is reached at about age 77 for the average Australian male.
2. Life expectancy for people with Type 2 diabetes is substantially reduced, possibly up to 10 years. If I need to find credible data, I will, but I am sure the forum medical experts will have such data on-hand and should be happy to quote.
3. Thus, the absolute annual risk of death for 75 year old "Jim" with diabetes, plus CASA-documented high cholesterol, plus CASA-documented high blood pressure is "significant" / "non-trivial". You don't need advanced maths/stats to know that it's "significantly higher" than the 4% annual risk for the average 75 year old male. As a guide, IFF the life expectancy for a Type 2 diabetic Australian male is, say 75, then Jim had a 50% total chance of already being dead at the age CASA renewed his Class 1 medical certificate. Despite my limited medical expertise, I am confident that death is regarded as an incapacitating condition with substantial negative consequences, even among lay-people. And that's before we consider what other non-death incapacitations diabetic old "Jim" might also be at a higher risk of suffering (it's debatable whether we should lump in the full risk of Jim's actual factual stroke with the general elevated risk factors already identified for Jim - it's a veritable smorgasbord of possibilities for his age and documented conditions).

I have read the Ambekar and Adamczyk studies, and it is not credible to contend that CASA's approach between Clinton's case and Jim's case is objectively consistent from a statistical safety-driven standpoint. The only way to get close (from a statistical risk viewpoint) is to assume that the consequences of (just a) recurrence of a DAVF after having been "nominally cured" (ie. Clinton's current state) is worse than the consequences of actual death. I don't need to be a specialist in anything, or beat my chest about experience/qualifications to state authoritatively that the incapacitation consequences of DAVF recurrence cannot be worse than the incapacitation consequences of death.

So, for those of you who think CASA's approach in these two cases is "consistent", please explain what stats, studies and numbers you are using to justify your "trumps". For me, it's just about the numbers - and using population-level stats, plus CASA's own published information and cited studies, their approach to pilot incapacitation risk/safety cannot be described as consistent in these two cases.
It's also obvious that if the default approach is: " we're not sure, so we'll ground if in doubt and defend initial decisions no matter what", then pilots have a strong vested interest in never revealing anything voluntarily to their regular GP or "DAME". That's objectively a sub-standard outcome.
And a CASA medical officer who effectively instructs an "independent expert" doesn't seem confident that his own conclusions will be confirmed. This behaviour is indefensible [in a decision review scenario].
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Old 17th Dec 2018, 19:24
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Interesting comparison, FE.

I’d be surprised if CASA’s “Jim” is a real case study. If he is, good on him for managing to maintain a Class 1 medical certificate to the age of 75 with type 2 diabetes and high cholesterol and high blood pressure.

But, like you, I don’t know how CASA could reasonably come to the view that, if you take a sample of 100 Jims, there’s a less than 1% risk that one of them will suffer sudden incapacitation in their 75th year. Maybe I’ve misunderstood how CASA’s magic percentages work. Nowluke might be able to clarify.

I agree with your view that the terms of the letter from the CASA decision maker to the “independent” expert were “unforgivable”. As I’ve said, it was in my view biased and intellectually dishonest. Which brings up another interesting comparison: The ‘uber’ specialist I’m seeing has instructed me as follows: “Please note, Professor [X] does not review documentation until after he has seen each patient, to allow the taking of an unbiased history and physical examination.” I’m relieved that at least he gets the concept.
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Old 18th Dec 2018, 18:57
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A PPRuNer sent me a PM saying that he wanted to post the following, but thought better of it. However, he is happy for me to post it without attribution:

Is there anyone else besides your truly, who feels that this whole thread is quite disturbing?

The reason I have reached this opinion is that over, say the last four or five years, I have had a number of Medicos, including several DAME's say to me the following words;

"The less they (CASA Avmed) are told, the better!"
That experience is typical.

There are very sound reasons for that advice.

But at least in those cases the pilots are talking to doctors and getting assistance. My primary concern - and the reason for my view that Avmed is now a force inimical to aviation safety - is that there are now pilots who are too scared to raise issues with any doctor, for fear of it getting back to Avmed.
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Old 19th Dec 2018, 00:26
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“the most important consideration is safety”
Having a full and open discussion with your DAME can result in you offering information which gets you grounded for potentially long periods.
An indefinitely grounded pilot is the safest pilot...
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Old 19th Dec 2018, 01:11
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For Flight_Engineer - your assumptions and conclusions are incorrect. Whilst death is an outcome for everyone and its all cause rate after a certain age approaches 100% (somewhere near 117). This does not then mean that the risk acceptance threshold changes or if your other condition risks are less than this then the system is flawed. As before, the risk decision is composed of the full view of the "rate of unacceptability at which the hazard is realised when an appreciation of the condition in the environment is made with respect to the standards acceptable within the safety management system. This rate is whatever is set by the regulator and it is the best that can be made with the scientific, not single expert, knowledge available". Yes death is a single event, yes it is pretty bad (for the individual and whoever is nearby in the aircraft) but whilst the individual effect is large, the statistical event risk is lower than a plethora of other safety significant events (or risks of events).

The hazard is not death (although that is an outcome), it is the condition or treatment causing impairment &/or incapacity &/or death &/or the aviation environment effects and/or mitigations on the condition over the term of the licence.

I would be surprised to hear of anyone flying on a Class 1 CPL/ATPL internationally over 65 and domestically without investigations every 6 months and would also be surprised if companies employ them (in a passenger flying role) over 70 (and only domestic multi-crew) at all for broader insurability reasons (partly due to that all cause death rate you raise). Noted though there are some QFI/FIs flying students well into late 60's/early 70's, again with some pretty strict conditions.

The proposal of "never tell anyone" about medical issues and describes an attitude of wilful violation of the broader safety system and a lack of integrity. The, "I know best" and "if you mention anything you'll be grounded" combination will undermine safety even when there isn't mistrust in the system- and there are no quick fixes when those under regulation actively undermine that system. It is also under-appreciated that the decisions that are made are in the broader public interest rather than the individual.

It's nowhere near perfect and people will be upset, your response to actively mismanage one's own occupational healthcare puts others lives, property and reputation at risk in a repugnant and self-indulgent way that no one would reasonably support.

If you transcribed some of these conditions under discussion to the engineering space and started talking about 15%, 40% yearly failure rates or degradations of critical engine/flight surface parts then I'd say there would be some spirited discussion of continuing to use those parts...

Vis your magical Jim, no idea what the detail is. You could very easily sign off on anyone on a class 2 for VFR, daytime flying in remote contexts and then restrict the operating area - i.e. cattle surveying/remote property access work in a defined area and then add on multi crew restrictions or time limits, whatever mitigates the risk, in context, to an acceptable level. If the risk is indeterminate or there are multiple risks/risk factors then a conservative approach is always going to be the case. The other considerations though are much lowered if the only victim is yourself and your private property. Similar processes occur in the road transport context. The regulator is not going to do the legwork to demonstrate or research these mitigations without government direction.
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Old 19th Dec 2018, 02:08
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The problem with CASA is they place to much emphasis on statistics, and not actual data on persons
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Old 19th Dec 2018, 02:52
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Nowluke, you are either a troll or wilfully ignorant about the subject of risk. There are rigorous processes for managing risk available right now ((even from ICAO) that you do not seem to have any understanding of, or, like the regulator, CASA, you do know but prefer your own brand of self serving necromancy to established fact,

This rate is whatever is set by the regulator and it is the best that can be made with the scientific, not single expert, knowledge available".
There are current ICAO standards for the probability of death via aviation, there are also numerous actuarial metrics. From memory we are talking of the order of forty million to one. These are internationally accepted standards for risk. Neither CASA nor the AAT seems to make use of these datums which is a crime.

The proposal of "never tell anyone" about medical issues and describes an attitude of wilful violation of the broader safety system and a lack of integrity. The, "I know best" and "if you mention anything you'll be grounded" combination will undermine safety even when there isn't mistrust in the system- and there are no quick fixes when those under regulation actively undermine that system. It is also under-appreciated that the decisions that are made are in the broader public interest rather than the individual.

It's nowhere near perfect and people will be upset, your response to actively mismanage one's own occupational healthcare puts others lives, property and reputation at risk in a repugnant and self-indulgent way that no one would reasonably support.
Sanctimonious codswallop. The alleged "broader safety system" lacks even a shred of integrity as evidenced by the regularly reported bizarre behaviour of CASA staff including Avmed and despite the numerous pleadings, reviews and negotiations attempted by industry. Given that the system is broken there is no safety case to undermine.

As for your appeal to "the public interest" you must be joking. To educate you, any test of what "the public interest' is actually involves two components; the cost to the community of an event (a medical incapacitation causing an accident) versus the cost to the community of mitigating the risk of said accident. IT IS THIS SECOND HALF OF THE EQUATION THAT IS NEVER CONSIDERED BY YOU AND CASA - AND THOSE COSTS ARE HORRENDOUS!!!!!

The result is a system of regulation that has destroyed thousands of jobs and billions in investment (let alone opportunity costs) without saving the community from any meaningful expense at all. So much for your notion of public interest. You have to take into account the cost to the community of regulation and this seems to have escaped both CASA and you. Again there are ICAO metrics and procedures available right now to do these calculations.

Other jurisdictions have considerably better and more relaxed regulatory environments. Their publics profit from it and their skies aren't raining aluminium either.
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Old 19th Dec 2018, 04:22
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Vis your magical Jim, no idea what the detail is.
As FE explained, it’s a scenario on CASA’s website in the Avmed section: https://www.casa.gov.au/licences-and...based-scenario

I’d be interested in your expert opinion on the “magical Jim”, once you’re across his details.
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Old 19th Dec 2018, 04:47
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ICAO provides a medical framework which Australia/CASA aligns to in our environment, large portions will be wholly adopted or partially will be with localising changes and there will be exceptions. I am familiar with the medical standards and know there is a large amount of flexibility in their application and guess what, a nation can put any further restrictions or exemptions in place that it feels are necessary. These deviations are on the air services website. The loose wording of the standards, I would say, purposefully allows a large amount of latitude for medical issues. Further, for this case, ICAO is silent on these clinical particulars.

I don't agree with your goading tirade or the position that some enormous harm is being manifested. Your absolute position- that it's all f#%$ed, no planes are crashing and there's river of cash and jobs we're missing out on sounds like a politician's fever dream. Unfortunately there is a culture of grievance and refusal to accept a situation when it doesn't match an entitled opinion. If there is such a swathe of systemic issues then stand up a (new) senate committee or write to your MP and put them to light. Blowing hard on the internet's not likely to do much.

I agree the system has (not insurmountable) issues and in the medical space it can be extremely difficult to run a situation down to a statistical value. As I've repeatedly said, you're never going to have a regulatory organisation accept a critical/catastrophic risk scenario in the absence of quality data without a period of non-event to support it. End of.

Last edited by Nowluke; 19th Dec 2018 at 04:50. Reason: Spelling
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Old 19th Dec 2018, 04:51
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And your expert opinion on the “magical Jim” is?

Surely CASA wouldn’t fabricate the scenario.
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Old 19th Dec 2018, 04:56
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Originally Posted by Nowluke View Post

you're never going to have a regulatory organisation accept a critical/catastrophic risk scenario in the absence of quality data without a period of non-event to support it.
Yet they allow aircraft to take off every day.
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Old 19th Dec 2018, 05:02
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...because there is quality data that those risks are improbable or negligible (post mitigations)...

Last edited by Nowluke; 19th Dec 2018 at 05:26.
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Old 19th Dec 2018, 05:15
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vis Jim, it all appears pretty reasonable, he probably would have met the threshold in some guidelines for some more invasive cardiac screening (CCT/Angio) years before his stroke if you take him as a Class 1 who does single pilot air show work and some instructing. Retrospectively his condition may have been present for a number of years prior and wasn't/couldn't be detected. If all of the required/indicated investigations were negative and then guidelines stratified him into lower risk cohorts of diabetic, hypertensive elderly men he may not be (in the narrative he obviously isn't') above the level where his Class 1 is revoked. What's the exact issue? There is a conflict though at around that age, where as it was raised, it doesn't really matter how many negative tests you have, it's getting close to closing time percentage wise- this conflict I understand is based on age discrimination issues, you can't blanketly revoke licences on that basis and there aren't sensitive enough tests to demonstrate prospectively what pathology Jim has.

Post his event they made him fly privately with QFI only as a mitigation as out of 100 Jims much more than 1% will suffer an incident, not going to be a fun day for the QFI though as Jim's 10 through 38 keel over and not appropriate to have it occur in a commercial context i.e. multicrew as a mitigation (although it could be feasible in a younger, less comorbid individual as their culminative hazard would be less but that's a different story).
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