Part 3: Psychological Screening After Germanwings Crash

Mental Health Screening for Pilots

Apr 6, 2015

by John Ogle, MD, MPH, FACEP

Commercial Pilot / USAF Flight Surgeon


The Germanwings crash series examines aircraft-assisted homicide from an aviation medicine perspective. Airline pilots are exposed to stress on and off of the job. Although mental health can never be perfectly assessed, internal and external safeguards give airlines an enviable safety record that exceeds other inherently risky industries. Grounding policies can not perfectly anticipate every unique pilot crisis, but ideal workups attempt to uncover treatable medical then psychiatric diagnoses.

Overview: Pilot Mental Health Screening

This is part 3 in our Germanwings crash series about aircraft-assisted homicide. The previous section introduced the general medical duty to monitor aviator health, and this segment focuses specifically on the mental health portion of pilot screening.

Internal Safeguards

As the first line of defense, pilots monitor their own health. Aviators learn that they must self-report medical and mental health problems. In the US, it is illegal for a pilot to fly as a flight crewmember, while the pilot:

Knows or has reason to know of any medical condition that would make the person unable to meet the requirements for...the pilot operation; or Is taking medication or receiving other treatment for a medical condition that results in the person being unable to meet the requirements...for the pilot operation.
Source: Title 14 CFR ยง 61.53

Personal Checklists

Today's Air Force and civilian companies support similar safeguards through Operational Risk Management (ORM) programs, and crew rest requirements. Self-assessments like the I'M SAFE checklist remind pilots to pause momentarily and reflect on potential self-grounding issues. If pilots deem themselves mentally or medically unsafe, they're obliged to stay on the ground that day.


Pilot's Personal Preflight Self-Assessment Checklist

  • Illness
  • Medication
  • Stress
  • Alcohol
  • Fatigue
  • Eating

The World Health Organization (WHO) created an acclaimed Surgical Safety Checklist based on success from the airlines. The WHO preoperative safety tool requires a "time-out" prior to first incision in surgical practice.

Beyond passive requirements for self-monitoring, all Airmen must actively attest in writing to prior problems when giving their medical history during the online application phase of their flight physicals (MedXpress). Fraud penalties include fines up to $250,000 and/or 5 years in prison (Title 18 U.S. Code. Secs. 1001; 3571).

Ongoing Aviation Psychological Screening - Trust but Verify

Most pilots are high-functioning and trustworthy. The "honor system" usually works , but flyers also face external validation. The aerospace community aggressively patrols itself. Air Traffic Controllers, fellow aircrew, airport managers, instructors, check pilots, employers and medical examiners comprise the self-policing culture of aviation. Multiple observers monitor medical, practical and psychological status of pilots along multiple dimensions.

Family, finance, work and legal stressors present emotional risk factors for everyone. Pilots occsionally manifest acute psychiatric disorders such as severe depression, anxiety or dissociation. Because episodes can not always be foreseen, airline co-workers are trained to watch and report clues of pilot impairment such as missed radio calls, inattention to checklists, excessive absenteeism, or sloppy appearance.

External Safeguards

Beyond internal checks and informal supicions, external checks cover situations where pilots lack insight, or are purposely evasive. Pilots are grounded when background checks uncover DUI or other unreported crimes. Random drug testing for pilots is common. Commercial pilots knowingly forfeit some personal liberty when they chose a career as an airline professional.

Most airlines, including Lufthansa, require pilot applicants to undergo personality profiling at hiring time. Psychometric assessments measure aptitude for problem solving, communication and teamwork skills. Ongoing mental stability is better evaluated on the job or during the recurrent practical examinations such as flight checkrides and simulator evaluations. The aviator scrutiny concept can be difficult for the non-flying, privacy-loving public to grasp, but it is credited for the impressive airline safety record.

FAA Mandated Mental Health Evaluations

When warranted by AME observations or pilot-provided history, the FAA may require the pilot get a formal aviation mental health evaluation. This is an independent psychological, psychiatric or neuropsychological assessment reported directly to the FAA who will then make the ultimate disposition (fly or no-fly).

FAA Mental Health evaluations require the pilot to send records to the FAA including academic records, records of prior psychiatric hospitalizations, and records of periods of observation or treatment (e.g., psychiatrist, psychologist, social worker, counselor, or neuropsychologist treatment notes). Records must be in sufficient detail to permit a clear evaluation of the nature and extent of any previous mental disorders.

Ideal and Actual Workups

AME guidelines require that pilots be denied flight privileges if they have a personality disorder manifested by overt acts, a psychosis or a bipolar disorder. Practically, these diagnoses are not clear cut (mood swings vs bipolar?), and the information pilots provide about previous diagnoses may be incorrect because the specifics are unclear or unknown to them. A few pilots deliberately minimize past problems to pass the flight physical.

AMEs and flight surgeons observe appearance, behavior, mood, communication skills, memory and cognition, but the doctor's snapshot impression is dependent on self-reporting and the apparent state of the pilot during the brief flight physical. Occasionally pilot candidates are referred for neuropsychological testing to further clarify borderline cases.

Grounding Policy

From a policy standpoint, no single stressor or request for help should automatically ground a troubled aviator. However, when problems are identified through self-disclosure, candid interactions or objective observations, most airlines aim for methodical workup starting with a focused medical evaluation (endocrine, sleep apnea, etc). Next is a mental health review for depression, personality disorder, substance abuse or anxiety.

Idealized responses are important but not always attainable in the real world, so privacy protections and predictive limits of psychiatric screening are addressed later in this series. It is unknowable whether any proposed measures could have confidently detected or predicted Germanwings co-pilot Andreas Lubitz's future state of mind.

Next WayPoint - Pilot Medical Privacy

This segment discussed pilot mental health screening and the series continues with the next segment, Part 4: Privacy Protections: Pilot Medical Records... →

Continue to Part 3: Ongoing Mental Health Surveillance →

Author: John Ogle, MD, MPH, FACEP is one of our senior flight surgeons. An Emergency Physician and commercial pilot himself, the author holds degrees in aerospace engineering, medicine and epidemiology. He is an experienced Air Force crash investigator and former AME.

Editor's Note: This series contains Dr Ogle's personal and professional opinions. His preliminary ideas may or may not reflect those of the FAA, the US Air Force or Details of the horrific crash are still emerging at the time of publication.

— Editorial Staff

Reminder: use to familiarize yourself with aviation medical regulations and guidelines, but always discuss your specific situation with one or more AMEs before dedicating resources toward expensive clinical workups. Find an AME now