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

[Clinton McKenzie]

Is their '12 months' based on some precedent or standard, however derived, or is it an arbitrary number that could be subject to some further judicial review of administrative action ?

The refusal, outright, to do any assessment during the 12 month period is, in my view, a manifestation of a couple of errors of law in the delegate’s decision that are easily demonstrated. However, for reasons I’ll explain, there’s little practical point in applying to the Federal Court for orders to the effect that the delegate should comply with the law.

Unsurprisingly - except perhaps for Avmed - delegates are supposed to exercise their powers on the basis of the specific circumstances relevant to the particular case in question. The potential risks of a medical condition posed to and by a day VFR pilot are not the same as the the potential risks of the same medical condition posed to and by an IFR-rated aerobatic-rated pilot who does single pilot IFR as a day job. (Note: the phrase “to and by” the pilot is important.). Further, delegates are not supposed to be dictated to by policy or administrative rule.

Accordingly, one of the numerous circumstances that the ADJR Act says is an improper exercise of power is:

[A]n exercise of a discretionary power in accordance with a rule or policy without regard to the merits of the particular case.

It’s obvious to me that Avmed has a policy simply to refuse to assess and make any decision on any evidence during the 12 months following the procedure I underwent. (Avmed has ‘form’ on making decisions under the dictation of policy. At one level this is not surprising, because Avmed does not have specialist expertise in the subject matter. )

The refusal is also, in my view, contrary to CASR 67.240(4), which says:

(4)If:

(a) CASA suspends a medical certificate; and

(b) the holder of the certificate submits to an examination or test directed by CASA, or authorises the disclosure of information to CASA; and

(c) the examination, test or information shows that:

(i) the holder meets the relevant medical standard; and

(ii) the continued holding of the certificate by the holder will not adversely affect the safety of air navigation;

CASA must:

(d) end the suspension; and

(e) tell the holder in writing that the suspension has ended.

If the delegate’s letter is taken at face value, the outcome is that the delegate is simply going to refuse to change his mind during the 12 month period. I can only continue to assume the delegate meant what he said, because he steadfastly refuses to provide written confirmation that he will make assessments of evidence I submit and potentially form a different view during the 12 month period.

Why wouldn’t I go to the Federal Court and get this stuff tested, when my ‘day job’ is administrative law litigation and I’m am able to afford it? Because there is no practical point. If I’m correct, all that will happen is that CASA will be directed to assess during the 12 month period. I already know what CASA’s assessment will be - there is little-to-no chance that Avmed could approach the assessment in an objective, unbiased way.

Where does the 1 year come from? I’m guessing it’s from the graph in the Ambekar study that’s selectively quoted in the selected ‘Relevant Medical Literature’ annexed to the delegate’s statement to the AAT.

Let’s assume the material gathered by the delegate is a complete compendium of relevant studies. (A patently invalid assumption.). Let us also assume that no findings of any study have ever been subsequently proved wrong or inaccurate. (Another patently invalid assumption. My favourite study is “Why Most Published Research Findings Are False” by John P. A. Ioannidis.)

Even given those assumptions, Avmed mixes up the different probabilities described in the Ambekar study. There are the probabilities of when a recurrence of a previously treated fistula will occur - usually during the year following the treatment. But those are not the probabilities of it occurring.

As I’ve said earlier, if Avmed walked the talk, it would be assessing the probabilities of recurrence. It would also be assessing the probabilities of the recurrence causing sudden incapacitation. If Avmed understood how the relevant probabilities work, it would know that the first times the second equals a very remote probability.

In my case, I’ve already had a high quality dynamic CT scan over 2 months post the treatment, which is already past the 80% point on the Ambekar graph, confirming the ongoing effectiveness of the treatment. But given Avmed’s current position, Avmed would view the images from that scan like a dog watching television.

[Clinton McKenzie]

Over a decade ago the AVMED section had a chief who had the reputation of being willing to pull Class One's for anything imaginable, apparently he just had the need.

That might have been erstwhile PMO Pooshan Navathe. Many careers and life’s passions were destroyed under his watch. It was he who returned Australia to the dark ages on the CVD issue. All in the name of ‘safety’ of course.

My favourite comment on Navathe was made by Deputy President Hack SC (in this AAT decision Bolton and Civil Aviation Safety Authority [2013] AATA 941 (23 December 2013)):

Dr Navathe’s witness statement concluded [in terms quoted by the AAT].Despite the fact that the statement does contain the declaration of duty required by the Guidelines it could not be plainer that Dr Navathe is an advocate for his own decision. I do not propose to have any regard to his opinions. For the future I would trust that CASA’s Legal Branch would exercise independent judgement in deciding what witnesses ought be relied upon and the content of their statements. They ought, obviously enough, be confined to matters that are relevant and witnesses ought be those who can truly provide an independent opinion.

The delegate who decided to suspend my medical certificate is Dr Sharma.

Dr Sharma provided a statement to the AAT prior to the stay hearing.

That statement contained the declaration of duty required by the Guidelines.

Unsurprisingly, Dr Sharma’s statement is to the effect that his own decision was a good one.

[Clinton McKenzie]

CASA’s response to my request that the delegate confirm, in writing, whether or not he will consider and review the substance of medical evidence submitted to CASA, and make actual risk assessments from time-to-time based on that evidence, during the specified 12 month period following the date of the emoblisation procedure:

Dear Clinton,

Further to your letter of 14 November 2018 and as previously advised , you may at any time submit further material and/or reports in support of the lifting of your suspension of your Class 2 medical certificate and CASA will give timely consideration to such material as and when received. The type of material which would be of greatest assistance is as set out in the direction letter - namely opinions from Dr Lalloo and Dr Mews dealing with the specific listed issues relevant to determining ongoing certification.

A reminder of what the delegate said in the decision letter:

Please be advised, CASA is unable to make a risk assessment of your fitness to return to flying until 12 months has elapsed following your embolisation procedure.

I think “give timely consideration” is CASA-speak for “presumptively ignore”.

[Fantome]

Why do some get their medical clearance quickly and others take months, with no explanation except a big backlog to get through? I completed Class Two renewal in May but did not get the certificate issued till 20 October. (Despite numerous phone calls.)

[Clinton McKenzie]

Based on the - quite disturbing - conversations I’ve had recently, I’m guessing you or your DAME upset Avmed’s computer program. Once you upset Avmed’s computer program, Avmed humans get involved. Once Avmed humans get involved, they feel compelled to add ‘safety’.

[Squawk7700]

At my last medical renewal I upset the avmed computer by ticking a “yes” checkbox for a very benign procedure that was signed off by Australia’s foremost orthopaedic surgeon to the stars and it took them months to renew it. I felt compelled to tell them because it felt like the right thing to do at the time, as my dame would no doubt see the scars at my next renewal.

Every time I rang them on a Friday which is what they asked me to do, they would tell me that the avmed doctors were only part time working from home and they hadn’t got to mine yet and to call again next Friday.

[On eyre]

Should’ve ignored their advice and rung on Monday, Tuesday,Wednesday and Thursday continuously ��

[The Wawa Zone]

Clinton, if you as a former CASA OLC goon and current administrative law lawyer can't get this sorted then the ordinary sick people are screwed.

That might have been erstwhile PMO Pooshan Navathe. Many careers and life’s passions were destroyed under his watch. It was he who returned Australia to the dark ages on the CVD issue. All in the name of ‘safety’ of course.

No, but one who sounds much the same. 2004-ish. I had to talk to him once about blood-in-the-urine at a Class 1 med renewal and I made a point of putting everything in the context of questions that only a Doctor of his brilliance could answer, and he didn't start thinking about ways to get me to spend another $2k on tests.

[Clinton McKenzie]

I think you’ll find that Avmed now presumptively ignores the opinions of even the specialists who treat “former CASA OLC goons”. (That is unless the opinions are against the interests of the goon, in which case they’re considered by CASA to be an objective truth. CASA is at least consistent in what I consider to be a biased approach.)

Meanwhile, I underwent intravenous digital subtraction angiography on Friday. The results stated in the report: “entirely normal”.

So the timeline and specialists’ opinions are:

- treatment in August, expressed to be a success

- I’m OK to fly day VFR, stated in a letter in October

- results of dynamic CTA scan on 6 November don’t indicate anything wrong

- results of intravenous digital subtraction angiography on 30 November are “entirely normal”.

In case anyone overlooked a key point in my previous posts: My surgeon is a pilot.

Against these opinions is CASA’s non-specialist opinion based on selected (acknowledged as such by CASA) and in my view misconstrued studies.

I held a medical certificate and continued flying while I was unaware of the existence and potential consequences of a condition. The condition was then identified and treated, and the specialists who carried out the procedure say the treatment was successful, everything is “entirely normal” and I’m fit to fly day VFR. Only in the weird and whacky world of Avmed could it make sense that I should not now have a medical certificate enabling me to fly day VFR. Sure: Avmed will be able to come up with studies to show that there’s ‘some’ risk of sudden incapacitation. But I can come up with studies that show everyone’s ‘some’ risk of sudden incapacitation, just as everyone’s at ‘some’ risk of being struck by a meteorite.

And apparently it’s OK for me to drive a petrol tanker past airports and schools, in all weather conditions day and night.

I did laugh like a drain as I watched CASA on 19 November try to justify a regulatory regime in which self-certified pilots are allowed to mix it with RPT jets in G airspace but, by implication, I’m too dangerous to do so as well. I recall helping one of those pilots at a fuel bowser at a place that will remain nameless - Even with glasses he couldn’t read the instructions and keypad on the bowser.

Fortunately one of the most significantly causal contributors to aviation safety in Australia is the low density of traffic.

My primary concern in all of this is that Avmed is now, in my view, a force inimical to aviation safety.

It wasn’t so bad when all they were doing was destroying careers and life’s passions - that’s just money and personal satisfaction. At least that outcome does not have a negative impact on safety, in the sense that there would be no negative impact on safety if all Caucasian males were prohibited from flying. And it wasn’t so bad when there was a substantial increase in the number of medical conditions undisclosed to DAMEs and CASA, but dealt with ‘underground’. At least the conditions were dealt with.

However, it’s now got to the point at which some pilots are simply too scared to tell any doctor anything ‘when in doubt’, for fear of what would happen if Avmed became aware of a potential medical issue. Think of the dilemma faced by a pilot who’s considering talking to a doctor about a potential mental health issue, when the potential outcome is being ‘grounded’ or directed to undergo intrusive and expensive examinations while being presumed a potential GermanWings criminal.

There is now a material possibility that someone ‘up front’ of an aircraft is too scared to talk to a doctor about a potential medical issue, for fear of Avmed. That is not good for aviation safety.

CASA waves this away on the basis of the frequency of DAME examinations and the multi-crew environment. As always, any potential downsides of CASA Avmed’s behaviour are ‘spun’ as being justified, and inconvenient truths like single pilot IFR downplayed.

Avmed chooses - note it’s a choice - to give greater weight to any evidence of potential medical unfitness compared with any evidence to the contrary. That’s not, in my view, treating the safety of air navigation as the most important consideration. That is, in my view, bias. That’s not, in my view, objective evidence-based and objective risk-based decision-making. That is, in my view, intellectually dishonest.

[Sunfish]

As I said before, employment conditions for most public servants are such that there is zero incentive to give you the benefit of the doubt and a massive positive incentive to minimise their personal career risk be minimising your chances of flying and possibly having an accident that might be sheeted home to a medical condition. this has to change.

[Clinton McKenzie]

A conference occurred in the AAT on Monday 3 December. There is to be a conciliation conference on 1 April 2019. The date may be propitious …

About the only substantive material of interest to readers is that I obtained access to the letter sent by the CASA decision-maker seeking supposedly independent specialist advice. The content of the letter confirms for me that CASA has either forgotten or has decided simply to ignore what the AAT said in the Bolton matter. My guess is that Avmed simply chooses to ignore what the AAT said. Not for Avmed the mere bagatelle of doing things in an objective, disinterested way.

Before setting out extracts of the letter from Avmed supposedly seeking independent specialist advice, it’s worth reviewing what the AAT said in the Bolton matter, and why. The decision (here:https://www.austlii.edu.au/cgi-bin/v.../2013/941.html ) says, at paragraph 24:

Despite the fact that the statement [of erstwhile PMO Dr Navathe] does contain the declaration of duty required by the Guidelines [for Persons Giving Expert and Opinion Evidence] it could not be plainer that Dr Navathe is an advocate for his own decision. I do not propose to have any regard to his opinions. For the future I would trust that CASA’s Legal Branch would exercise independent judgement in deciding what witnesses ought be relied upon and the content of their statements. They ought, obviously enough, be confined to matters that are relevant and witnesses ought be those who can truly provide an independent opinion.

It didn’t end there. The AAT went on to say, at 25:

It is not known what documentary material was provided to [the specialist] nor is it known what was conveyed to him by Dr Navathe in the conversation on 1 November 2013. Moreover, it is highly irregular that one expert witness, who is as well the primary decision-maker, was apparently briefing another expert witness in terms not disclosed. The danger of such a practice ought to have been evident. The vice is merely compounded by the failure to make clear what information was conveyed.

I find it breathtaking that the fundamental concepts underlying the AAT’s reprimands were either not obvious to Avmed and its legal advisors or simply disregarded by them in conducting the Bolton matter. At this point I tend and want to believe it was just the arrogance of Avmed in the face of legal advice to the contrary.

The underlying reason for those reprimands from Deputy President Hack SC of the AAT is that people who provide expert evidence are supposed to be independent of and disinterested in the subject matter of the decision under review. Experts are supposed to be provided with objective facts on the basis of which the experts express an objective and unbiased opinion. Dr Navathe was evidently an advocate for his own decision. Thus he was evidently not independent and the AAT therefore did not have any regard for his opinions. Further, Dr Navathe took it upon himself to engage in the “highly irregular” practice of briefing the expert in terms undisclosed.

So fast forward to my matter. As I’ve previously posted, the decision maker in my matter is Dr Sharma. Dr Sharma provided a statement to the AAT in advance of the stay hearing. That statement includes the declaration of duty required by the Guidelines. And see if you can guess if Dr Sharma’s statement was advocating for or against his own decision.

Dr Sharma wrote to a specialist on 31 October 2018, seeking a medical opinion. I have extracted key parts of the letter below (and continue to be prepared to make entire copies available to anyone on request if someone wants to post them in this thread). I will leave others to assess whether this constitutes a disinterested request for an independent expert’s opinion based on the provision of facts to the expert:

OPINION SOUGHT

CASA holds ongoing certification concerns in view of the endovascular intervention for Mr McKenzie’s medical condition, the specified risks and probabilities outlined by Dr Mews and in the absence of evidence of stability of the ONYX procedure. [My notes: I again note Dr Mews’ opinions of the risks and probabilities are implicitly taken as evidence, but his opinion (and that of Dr Lalloo) as to the success of the procedure is implicitly dismissed as no evidence. Further, there is no causal connection with CASA’s concerns and my compliance or otherwise with the class 2 medical standard. CASA’s concerns are irrelevant to – or at least should be irrelevant to – the expert.]

Considering that Mr McKenzie is now only some 2 months post procedure it is also of concern as to the potential procedure-related risks viz. permanent neurologic morbidity or failure of the procedure requiring re-treatment, and the likely risks due to the medical condition itself (haemorrhage, venous congestion/intracranial hypertension, ischaemic neurological deficit or seizure). [My notes: Again, there is no causal connection with CASA’s concerns and my compliance or otherwise with the class 2 medical standard. CASA’s concerns are irrelevant. The word “only” is value-laden, as is the phrase “likely risks”. These are matters about which the expert is supposed to form an independent view.]

Mr McKenzie’s present proceedings before the Tribunal seek to review the suspension decision and potentially the need to provide further evidence as to his medical condition. [My notes: The assertion that I have a “medical condition” is merely that. It’s supposed to be up to the expert to express an independent view as to whether diagnosis X on Y date followed by procedure A on B date results in any ongoing issue months later.] He contends that the suspension is unreasonable since he has been medically fit during the 32 years of flying before the diagnosis of a pre-existing medical condition and that the recent “successful” medical procedure has reduced whatever risks arose from the DVAF. [My notes: My contentions are irrelevant to the specialist, or at least they should be. In any event, it was Drs Mews and Lalloo who expressed the opinion that the procedure was “successful”, that I am not a risk of incapacitation and that I meet the class 2 standard for day VFR.]

CASA considers such a submission to be untenable in that the issue is whether or not Mr McKenzie presently meets the Class 2 medical standard in all respects. [My notes: At least CASA got one thing right: there is only one issue. But the point is that all the other fluff is unnecessary and irrelevant to the specialist, or at least it should be.] Provided at Annex 2 are [sic] a list of identified studies of potential relevance to the matters under consideration. [My notes: More on the list later, but here you see one of the clearest manifestations of Avmed’s complete arrogance or complete misunderstanding of how independent experts are supposed to be briefed. They are not supposed to be spoon fed the decision-maker’s inexpert and selectively chosen and quoted studies that just happen to support the decision-maker’s own decision. I am completely astonished that CASA continues to do this, in the wake of the Bolton decision.]

CASA seeks your opinion (including supporting references) with respect to the following: … [There follows a list of mostly leading questions. My favourite is this one: “Do you agree with Dr Mews[sic] initial assessment of a 40% annualised malignant behaviour risk prior to treatment.” That’s not, in fact, what Dr Mews said. It’s Avmed spin.]

The ‘list’ is headed “Evidence elsewhere”.

The most breathtakingly inappropriate aspect of the list is not that it’s there at all (an independent expert is supposed already to have access to reference material relevant to their expertise, based on their own judgment, otherwise they aren’t experts); it’s not so much that the list is selective; and it’s not even so much that it is mostly selective in favour of material in support of the decision-maker’s decision, when the decision-maker is briefing the ‘independent’ expert. I get it now that Avmed just blithely operates in a way that is in my view biased and intellectually-dishonest.

The most breathtakingly inappropriate aspect of the selective and selectively quoted material is that there is emphasis added by Avmed! That is, Avmed has gone through and underlined and italicised text that is not underlined or italicised in the original source documents. Presumably this is so the “independent” expert can “independently” come to the view that the underlined and italicised text in the material selectively chosen and quoted by the non-expert decision-maker who happens to be briefing the “independent” expert is – surprise, surprise – specifically relevant to and – surprise, surprise – supportive of the decision-maker’s decision.

My favourite selectively quoted text with underlining and italics in Dr Sharma’s letter to the expert that is not underlined or italicised in the original text of the source document is this:

Even lesions apparently cured with embolic agents have been shown to recanalize, including potentially catastrophic bleeding. Hence, even apparently obliterated lesions with transarterial embolization should be followed with late confirmatory angiogram, after a few months, to confirm effective cure.

You got that, “independent” expert? The non-independent non-specialist decision-maker wants you to independently form the view that the text selectively quoted and emphasised is specifically relevant to your “independent” opinion.

Why is that my favourite? I have now undergone a “late confirmatory angiogram, after a few months, to confirm effective cure”. The intravenous digital subtraction angiogram I underwent on 30 November confirmed effective cure of the DAVF by the procedure I underwent on 23 August. By my maths, that’s a few months. I’m advised that intravenous digital subtraction angiogram is the ‘gold standard’ scan to confirm ongoing success in cases like mine. However, I have no confidence that Avmed will consider the results of that scan (or the results of the dynamic CTA scan from 6 November) in an objective way, even assuming Avmed had expertise to do so.

[Cloudee]

Thanks Clinton, your ability to interpret this stuff so a layman like me can see what’s happening I’d amazing. Putting this out in public is gold for all of us that have to deal with these clowns.

[Horatio Leafblower]

I will leave others to assess whether this constitutes a disinterested request for an independent expert’s opinion

....he said, and then pointed out in each paragraph why this doesn't constitute a disinterested request for an independent expert's opinion!

Seriously though - thank you for sharing this CM it's important that as much light is shone upon CASA's conduct as possible.

[Nowluke]

Leaving aside the details of your concerns with the application of administrative process and the roles of a regulator/accrediting body. I have no skin in the game or knowledge on that front, I have no CASA connection and empathise with your frustrations. It looks like you've not had a pleasant experience.

Nevertheless, you had a flight safety relevant condition which was treated using novel (i.e. new techniques) for which a significant body of long term evidence has not been generated. Your specialist opinions did not address the specific questions required in order to make a sound risk based decision. You then further complicated the process by acting as your own medical advocate with the avmed unit. Where was your DAME or GP in this process? Further complicating this you sought out 'tests' to provide secondary proof against a negative, which can't really logically ever be done i.e. "prove it won't happen"

There's an element of fixation around 12 months being 'required' to make a decision. Without diving into a large amount of academic papers, generally, any instrumentation of your brain, its vascular sctructures and the cavity it sits in has a significant risk of generating a (new) source of future seizures (i.e. risk) and causing damage/infection/bleeding. This risk is generally realised within the first 12 months if it is to occur and the corollary is that if its occurrence rate is less than once/year then it should generally be acceptable under most aviation contexts (or have mitigations applied to make it so).

There is no evidence that can be provided in the intervening time period as there is no clinical/investigatory test able to stratify the cohort- there is generally only evidence/results of higher risk i.e. a bleed/neurological symptoms/infection etc. or immediate short term 'treatment' success. That you have normal post intervention tests is reassuring you are not at a higher risk than baseline however the condition has risks of recurrence/treatment failure/complication that no test other than the passage of time exists to prove non-occurrence. A 12 month period is somewhat arbitrary but it is the objective statistical risk standard/threshold for decision making and there is some evidence for that period roughly correlating with a period of recovery healing/rehab and then physiological stabilisation (more towards the 6-12month time period). Much argument can be had over the 1% rule and its origins/assumptions but it is what is used and sets part of the standard.

The phrasing/process in the corro out of CASA, from your position, would not be compliant with admin process law or some similar position. It doesn't strike me as particularly troublesome in providing an independent opinion. Very specific hypothesis/questions/risk scenarios/assumptions need to be addressed with rigour. Provision of a supporting or dissenting opinion (with academic clinical research/analysis to support) against these is critical in coming to a reasonable decision against a risk framework (Meta-analysis, single quality study, other cohort research and then expert opinion form the hierarchy with most weighting to the former). The absence of an opinion (against not just "fit to fly today" but time based risk and long term consequences with quality research to back it up), as would appear to have occurred with your earlier reports has led to the ambiguity/lack of probabilistic statements against the risks. I would be very surprised if any reasonable person would then afford you the 'benefit of the doubt' rather than take the conservative position.

I'd likely consider you recommendable to be fit to fly Class 2 with restrictions after 12 months from your narrative but can't offer an opinion on an incomplete picture. The other question I would ask is that why not fly under an RPL or Basic Class 2 - if you VFR day fly only for your own pleasure? The emotional effort and time to 'fight' for a principle or against perceived slights is not going to be healthy for you in the long term.

[Cloudee]

Do you really think CASA would allow someone they have medically grounded to fly the same aircraft in the same airspace with a basic class two medical? If they would allow this, surely Clinton would have been offered this alternative medical standard.

[Clinton McKenzie]

I’ll be providing a detailed response to Nowluke’s (curiously first) post, tomorrow.

[Nowluke]

Feel free, first post as I haven’t had much to contribute. As you can check though, I have been a member for a while. I’m offering a perspective from a different part of the aviation community; take whatever value you wish, discard it if you want. As I said, it’s a shame you’re not flying, it’s doubly so that communication issues have compounded your distress.

[VH-MLE]

Was that Dr Luke Sharma posting? I smell an _________ here...

[Clinton McKenzie]

Nevertheless, you had a flight safety relevant condition which was treated using novel (i.e. new techniques) for which a significant body of long term evidence has not been generated.

Thanks for your opinion. I am not aware of what expertise and experience you have.

That said, I agree, based on the advice of specialists whose opinions I respect, that I did have a safety relevant condition. But note: I left out “flight”, because part of the problem with the Avmed paradigm is its self-interested insistence that aviation is ‘special’ with unique risks.

In fact, apart from the activities engaged in by fighter pilots and aerobatic pilots, there’s very little in aviation that entails some special demands on pilots, resulting in an objective justification for a special medical standard (even though pilots, wearing their own-worst-enemy hats, like to think otherwise).

Specialists with relevant, current experience disagree with your opinion that the treatment continues to be “novel” as you have defined it.

It’s an acceptable risk for me to continue to drive a car that weighs more than my aircraft and carries more people than my aircraft, on the road shared by buses full of school children a mere couple of metres away, day and night in all weather, when I’m apparently an ongoing potential neuro-circulatory time bomb. Were I to instead get into a vehicle of less weight with fewer passengers, usually kilometres from the nearest other people, apparently the risk of sudden incapacitation increases or the consequences become more catastrophic if there happens to be an air gap between the vehicle and the ground. That seems to me to be a nonsensical incongruity. However, I know why it exists - more on this later.

Your specialist opinions did not address the specific questions required in order to make a sound risk based decision.

Let me fix that for you: Apparently the specialist opinions do not address the specific questions that, in Avmed’s opinion, are required in order for Avmed to make what is, in Avmed’s opinion, a sound risk based decision by Avmed.

Were it the case that:

1. any of the medical professionals with whom I’m dealing were prepared to speak in glowing terms of Avmed’s expertise and decisions, and

2. I could find any correspondence or statement in this matter that is not replete with what I consider to be biased and intellectually dishonest spin by CASA, and

3. my specialists were unwilling to express any opinion as to my current fitness to fly,

then I might take Avmed’s opinions seriously and allocate weight to them compared with specialists with first hand knowledge of my circumstances.

What I find baffling is that when my specialists express the opinion that the procedure was a success, that I am not a risk of incapacitation and meet the standard for day VFR, it seems Avmed (and you) think those opinions were expressed just for ****s and giggles, or perhaps based on disembowelling a goat and reading the entrails or by consulting an astrologer.

The objective fact is that there is no causal connection between Avmed’s opinions and levels of knowledge or ignorance on the one had and my compliance or otherwise with the medical standard on the other. Or do I have that wrong?

You then further complicated the process by acting as your own medical advocate with the avmed unit. Where was your DAME or GP in this process? Further complicating this you sought out 'tests' to provide secondary proof against a negative, which can't really logically ever be done i.e. "prove it won't happen"

Bit hard to know where to start with that...

I haven’t “sought” any tests. I hate doctors (not on a personal basis), I hate hospitals (but love their work), I hate needles and I hate holes being punched in my groin so that tubes and contrast chemicals can be fed through my circulatory system.

I’ve undergone the kinds of scans that my specialists recommended I undertake, at the points in time my specialists recommended that I undertake them, in what they say is the ordinary course of follow-up tests in cases like mine. (And let me make this very clear: If it were otherwise, I would be taking action if my specialists have been ‘ordering’ scans in circumstances in which they would not ordinarily recommend them. However, I’m very confident that my specialists know what they’re doing, in my particular circumstances.)

I have no idea what you mean by “acting as [my] own medical advocate with the avmed unit”. I asked my GP and specialist to forward to Avmed whatever stuff that may be relevant to my case. My first post-procedure correspondence with Avmed was me forwarding to Avmed my GP’s letter to Avmed that I requested my GP to send Avmed, just to make sure Avmed had received it and I couldn’t be accused of withholding information from Avmed. My GP didn’t generate that letter as a consequence of sensing a disturbance in ‘the force’.

I visited my GP after the procedure. I had a follow-up visit with the specialist a few weeks after the procedure. Are you or Avmed worried that my GP and specialist failed to notice that half my face was paralysed, drool was running down my chin and I was in a wheelchair being led by a guide dog?

As to a DAME, what possible ‘value add’ could a DAME’s opinion currently be? Are you seriously suggesting that, having disregarded the specialists’ opinions, Avmed is going to do anything other than disregard the opinions of the non-specialist GP and DAME? (This was one of the fascinating things that CASA brought up at the stay hearing.)

I have repeatedly requested that the delegate confirm, in writing, that the results of scans carried out during the 12 month period post-procedure will be assessed by and potentially change the delegate’s position during the 12 month period. That request has repeatedly been denied. There’s been some sophistry in correspondence from a CASA lawyer, but the lawyer isn’t the delegate and the lawyer’s opinion does not determine the delegate’s position. For CASA to keep raising the issue of GPs and DAMEs in those circumstances is, in my view, simply disingenuous. CASA will ignore their opinions (unless, of course, they are against my interests) and GPs and DAMEs will defer to the opinions of treating specialists in any event.

There's an element of fixation around 12 months being 'required' to make a decision. Without diving into a large amount of academic papers, generally, any instrumentation of your brain, its vascular sctructures and the cavity it sits in has a significant risk of generating a (new) source of future seizures (i.e. risk) and causing damage/infection/bleeding. This risk is generally realised within the first 12 months if it is to occur and the corollary is that if its occurrence rate is less than once/year then it should generally be acceptable under most aviation contexts (or have mitigations applied to make it so).

In your opinion.

And what, in your opinion, is the percentage risk of a recurrence of or new vascular abnormality, multiplied by the the percentage risk of that causing sudden incapacitation? Or is this one of the circumstances in which it’s just OK to use words like “significant” or “high”, rather than specific numbers like 1% or 2% that apparently have some magical consequence. The insistence on specificity is selective. That selective insistence is, in my view, biased and intellectually dishonest.

There is no evidence that can be provided in the intervening time period as there is no clinical/investigatory test able to stratify the cohort- there is generally only evidence/results of higher risk i.e. a bleed/neurological symptoms/infection etc. or immediate short term 'treatment' success. That you have normal post intervention tests is reassuring you are not at a higher risk than baseline however the condition has risks of recurrence/treatment failure/complication that no test other than the passage of time exists to prove non-occurrence. A 12 month period is somewhat arbitrary but it is the objective statistical risk standard/threshold for decision making and there is some evidence for that period roughly correlating with a period of recovery healing/rehab and then physiological stabilisation (more towards the 6-12month time period). Much argument can be had over the 1% rule and its origins/assumptions but it is what is used and sets part of the standard.

Interesting opinions.

“There is no evidence that can be provided in the intervening period as there is no clinical/investigatory test able to stratify the cohort”. Really? There are eminent specialists in medicine and statistics who have different opinions. Or is yours an objective truth?

“Somewhat arbitrary”. Is that like being “a little bit pregnant” or “slightly heavy-handed”?

The “1% rule” is not a rule. That’s why much argument can and should be had about it. I realise that it’s a number that’s nice and simple and, therefore, compellingly attractive and easy to use to convince the AAT and others of its safety relevance. But the objective fact is that it isn’t a “rule” and there is no safety magic in it.

The phrasing/process in the corro out of CASA, from your position, would not be compliant with admin process law or some similar position.

I have no idea what you meant by that.

It doesn't strike me as particularly troublesome in providing an independent opinion. Very specific hypothesis/questions/risk scenarios/assumptions need to be addressed with rigour. Provision of a supporting or dissenting opinion (with academic clinical research/analysis to support) against these is critical in coming to a reasonable decision against a risk framework (Meta-analysis, single quality study, other cohort research and then expert opinion form the hierarchy with most weighting to the former). The absence of an opinion (against not just "fit to fly today" but time based risk and long term consequences with quality research to back it up), as would appear to have occurred with your earlier reports has led to the ambiguity/lack of probabilistic statements against the risks. I would be very surprised if any reasonable person would then afford you the 'benefit of the doubt' rather than take the conservative position.

And there we have it, writ large: Not an objective assessment of the risks and consequences, but bias towards the worst-case scenario, based on an appeal to the “reasonable person”.

And we know what Ace CASA always has up its sleeve: the cognitive bias of the “reasonable person” contemplating an aviation catastrophe. You should read all the relevant studies on cognitive bias. Scaring the public pays the bills.

I'd likely consider you recommendable to be fit to fly Class 2 with restrictions after 12 months from your narrative but can't offer an opinion on an incomplete picture.

Not to worry: I have specialists who’ve already expressed an opinion.

The other question I would ask is that why not fly under an RPL or Basic Class 2 - if you VFR day fly only for your own pleasure?

Not that it’s any of your business, but the answer is: I don’t want to. I’m pretty sure I still have choices in these matters.

The emotional effort and time to 'fight' for a principle or against perceived slights is not going to be healthy for you in the long term.

And here we see another ghastly irony of the Avmed system, writ large.

Avmed made an administrative decision that affects my interests. I am entitled to seek review of that administrative decision, and have done so. That’s how it’s supposed to work in a representative democracy supposedly subject to the rule of law. Your dismissal of my concerns as “perceived slights” suggests to me that you might not understand how government accountability mechanisms are supposed to work, and why, (but also, coincidentally, confirms for me that you are in the medical industry).

The practical consequence of the way in which Avmed chooses to administer the medical certification system is that people can simply be ground into submission through not having the resources to fight or - and this is the ghastly irony - through the stress that is ultimately deleterious their health. What a great outcome! Caused by people who claim to be medical professionals.

Let’s see if I can summarise: We should all just cop whatever decisions Avmed makes, because to do otherwise will be bad for our health. (What’s the name of that organisation which says non-compliance with its demands could be bad for your health? The name escapes me for the moment...)

The “principle” that I am actually fighting for is aviation safety.

There are very simple ways for holders of class 1 and class 2 medical certificates to avoid all of what I’ve gone through as well as keep their medical certificates. Very simple ways.

The way in which Avmed currently chooses to administer the aviation medical certification regime encourages pilots to choose those ways. Pilots are increasingly choosing those ways.

That is bad for aviation safety because it’s bad for the health of those pilots.

That is why Avmed is now, in my view, a force inimical to aviation safety.

Think about that and your opinions, the next time you jump on a commercial aircraft. And remember: you’ll be sharing the sky with self-certified pilots.

[megan]

And remember: you’ll be sharing the sky with self-certified pilots

That is always the case Clinton, irrespective of whatever system may be in place, unless of course we go down the Russian route where crew have a medical at the commencement of duty. You get out of bed on the day of duty and ask yourself, "am I up to it, yes or no?".