Revision of Medical Standards and Certification Procedures and Duration of Medical Certificates; Proposed Rule

DEPARTMENT OF TRANSPORTATION

Federal Aviation Administration

14 CFR Parts 61 and 67

[Docket No. 27940; Notice No. 94-31]

RIN 2120-AA70

Revision of Medical Standards and Certification Procedures and

Duration of Medical Certificates

AGENCY: Federal Aviation Administration (FAA), DOT.

ACTION: Notice of proposed rulemaking (NPRM).

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SUMMARY: This notice proposes an extensive amendment of part 67 of the

Federal Aviation Regulations (FAR) to revise airman medical standards

and medical certification procedures. This announcement, in part,

proposes to implement a number of recommendations resulting from a

comprehensive review of the medical standards announced in previous

notices. As proposed, this revision of the standards for airman medical

certification and associated administrative procedures of part 67 will

better provide for safety in the aviation system and reflect current

medical knowledge, practice, and terminology.

This notice also proposes to amend Sec. 61.23 of part 61 to revise

the duration of third-class airman medical certificates, based on the

age of the airman, for operations requiring a private, recreational, or

student pilot certificate.

DATES: Comments must be submitted on or before February 21, 1995.

ADDRESSES: Comments on this notice should be mailed or delivered, in

triplicate, to: Federal Aviation Administration, Office of the Chief

Counsel, Attention: Rules Docket (AGC-10), Docket No. 27940, 800

Independence Avenue, SW., Washington, DC 20591. Comments mailed or

delivered must be marked Docket No. 27940. Comments may be examined in

Room 915G weekdays between 8:30 a.m. and 5 p.m., except on Federal

holidays.

FOR FURTHER INFORMATION CONTACT: Carol A. Thomas or Dennis McEachen,

Aeromedical Standards Branch, 800 Independence Avenue, SW., Washington,

DC 20591; telephone (202) 493-4075.

SUPPLEMENTARY INFORMATION:

Comments Invited

Interested persons are invited to participate in the making of the

proposed rule by submitting such written data, views, or arguments as

they may desire. Comments relating to the environmental, energy,

federalism, or economic impact that might result from adopting the

proposals in this notice are also invited. Substantive comments should

be accompanied by cost estimates. Comments should identify regulatory

docket or notice number and should be submitted in triplicate to the

Rules Docket address specified above. All comments received on or

before the closing date for comments specified will be considered by

the Administrator before taking action on this proposed rulemaking. The

proposals contained in this notice may be changed in light of comments

received. All comments received will be available, both before and

after the closing date for comments, in the Rules Docket for

examination by interested persons. A report summarizing each

substantive public contact with FAA personnel concerned with this

rulemaking will be filed in the docket. Commenters wishing the FAA to

acknowledge receipt of their comments submitted in response to this

notice must include a preaddressed, stamped postcard on which the

following statement is made: ``Comments to Docket No. 27940.'' The

postcard will be date stamped and mailed to the commenter.

Public Meeting

Public meetings will be held in Washington, DC, Seattle, WA, and

Orlando, FL. A notice of the meeting times and locations will be

published later in the Federal Register.

Availability of NPRM

Any person may obtain a copy of this NPRM by submitting a request

to the Federal Aviation Administration, Office of Public Affairs,

Attention: Public Inquiry Center, APA-200, 800 Independence Avenue,

S.W., Washington, D.C. 20591, or by calling (202) 267-3484.

Communications must identify the notice number of this NPRM.

Persons interested in being placed on the mailing list for future

NPRM's should request from the above office a copy of Advisory Circular

No. 11-2A, Notice of Proposed Rulemaking Distribution System, which

describes the application procedure.

Background

On April 15, 1982, the FAA announced the adoption of Amendment 67-

11 (47 FR 16298; April 15, 1982) to the FAR (14 CFR part 67). The

amendment revised, among other things, the special discretionary

procedures for issuing airman medical certificates to persons who do

not qualify for certification under Secs. 67.13, 67.15, or 67.17 of the

FAR. In the preamble to that amendment, the FAA announced that, in

compliance with Executive Order 12291, Federal Regulation (February 17,

1981), it intended to conduct an overall review of the medical

standards in part 67 of the FAR. A complete review of the regulations

was needed to bring the standards and procedures for airman medical

certification up to date with advances in medical knowledge, practice,

and technology. Therefore, Amendment 67-11 was considered interim

clarification until a comprehensive review of the medical standards

contained in part 67 could be concluded.

The FAA began the review of the medical standards for airmen and of

its certification practices and procedures (47 FR 30795; July 15, 1982)

by requesting public comment. In addition, the FAA initiated a contract

with the American Medical Association (AMA) to provide professional and

technical information. The AMA presented its report, ``Review of Part

67 of the Federal Air Regulations and the Medical Certification of

Civilian Airmen'' (AMA Report), on March 26, 1986. The public was again

invited to comment on part 67 in ``Announcement of the Availability of

a Report'' (51 FR 19040; May 23, 1986). The AMA Report detailed the

results of a comprehensive review of the standards for airman medical

certification and of their application. The AMA Report considered

pertinent advances in the field of medicine since 1959, recommended

changes in FAA medical standards and explained the rationale for such

changes.

In a separate but related issue, on May 11, 1979, the Aircraft

Owners and Pilots Association (AOPA) petitioned to amend Sec. 61.23 to

require medical examinations for private pilots at 36-month intervals

rather than at 24-month intervals. In response to the petition, the FAA

reviewed the literature, surveyed the medical practices of the

Department of Defense, and considered a preliminary analysis of its own

aeromedical certification data. The FAA then contracted with Johns

Hopkins University to prepare a detailed statistical analysis of

information collected by the FAA from annual examinations on

approximately 31,000 air traffic controllers over a 15-year period. The

study sample was demographically similar and broadly comparable to the

private pilot population, and the examinations were similar to airman

medical examinations.

The Johns Hopkins University analysis confirmed an increasing

incidence of recorded pathology with increasing age, agreeing with the

data from the AMA report, but a relatively low incidence in young

individuals. Reducing the frequency of medical examinations could be

expected to result in an increased prevalence of undetected pathology

within the system. For the younger age groups, however, this effect

would be small. The Johns Hopkins analysis did not identify exact ages

at which the frequency of examinations should be changed.

In response to the AOPA petition to amend Sec. 61.23, the FAA

issued on October 29, 1982, NPRM No. 82-15 (47 FR 54414, December 2,

1982) proposing to amend part 61 to revise the duration of validity of

third-class privileges of airman medical certificates for operations

requiring a private or student pilot certificate. As proposed by Notice

No. 82-15, the requirement for a third-class medical examination would

have been changed to every 5 years for the youngest pilots then

increasing in frequency to the existing 2-year interval for older

pilots.

On September 27, 1985, prior to the issuance of the AMA Report on

its review of the airman medical standards and certification procedures

in part 67, the notice proposing to amend part 61 to revise the

duration of third-class airman medical certificates was withdrawn (50

FR 39619). The proposal was withdrawn, in part, because of issues

raised by the medical community. In addition, a regulatory evaluation

of Notice No. 82-15 suggested a slight increase in aircraft accident

fatalities if the then proposed third-class medical certificate was set

to 5 years for young airmen. Given the then pending issuance of the AMA

Report and the possibility that the report would provide better data on

which to base an evaluation of the safety concerns raised by the

medical community, the FAA decided that any future consideration of

examination frequency would be within the context of the outcome of the

comprehensive review of part 67.

On February 26, 1986, AOPA again petitioned the FAA to revise the

duration of a third-class airman medical certificate to 36 calendar

months for noncommercial operations requiring a private, recreational,

or student pilot certificate. The petition (Docket No. 24932) was

entered in the public docket and remains open.

On September 24, 1993, AOPA once again petitioned the FAA to revise

the duration of a third-class airman medical certificate to 48 calendar

months for a specific trial period for noncommercial operations

requiring a private or student pilot certificate. The petition (Docket

No. 27473) was entered in the public docket and remains open.

Based on the FAA's review of part 67, the FAA's judgment regarding

recommendations contained in the AMA Report, and on consideration of

all public comments in response to previous notices, the FAA proposes

to revise part 67, ``Medical Standards and Certification.'' The

proposed revision of part 67 will involve the incorporation of

additions and changes to specific medical standards, the scope of

examination, and the administrative procedures pertaining to airman

medical certification. In consideration of pertinent advances in the

field of medicine since the last significant revision of part 67, the

medical standards and certification procedures that are being proposed

reflect current medical knowledge, technology, and practice.

As stated in the notice withdrawing Notice 82-15, the duration of

airman medical certificates was to be reconsidered after the AMA's

report; however, the report provided no duration recommendation. The

proposal to revise airmen standards and certifications procedures and

the duration of airmen medical certificates was also addressed in a

January 1992 agency rulemaking review. The results of these events

supported the revision of part 67 and duration of third-class airman

medical certificates. A reevaluation of all studies and data collected

since 1982 supports a revision of the duration of third-class medical

certificates outlined in this proposal. Accordingly, the FAA is

proposing revisions to part 67 and to Sec. 61.23 of part 61 of the FAR.

Summary of Proposed Amendments to Part 67

The following is a summary of the substantive changes proposed in

this rulemaking. Because the FAA is proposing a complete recodification

of part 67, this summary states both the current and proposed section/

paragraph numbers.

1. Distant visual acuity requirements for first- and second-class

certification are changed to delete the uncorrected acuity standards.

However, each eye must be corrected to 20/20 as in the current

standard. [FAR Standards: Current Secs. 67.13(b) and 67.15(b); Proposed

Secs. 67.103(a) and 67.203(a)]

2. For third-class certification, the current 20/50, uncorrected,

or 20/30, corrected, distant visual acuity standard is changed to 20/40

in each eye, with or without correction. [FAR Standard: Current

Sec. 67.17(b); Proposed Sec. 67.303(a)]

3. For first- and second-class certification, minimum near visual

acuity requirements are specified in terms of Snellen equivalents (20/

40), corrected or uncorrected, each eye, at 16 inches and, after age

50, also include an intermediate standard (20/40) at 32 inches. This

replaces the current standard of V=1.00 at 18 inches for first-class

only. [FAR Standards: Current Secs. 67.13(b) and 67.15(b); Proposed

Secs. 67.103(b) and 67.203(b)]

4. A near visual acuity standard of P20/40, corrected or

uncorrected, each eye, at 16 inches is added to the third-class visual

requirements. [FAR Standard: Current (None); Proposed Sec. 67.303(b)]

5. Color vision requirements are amended to read: ``ability to

perceive those colors necessary for safe performance of airman

duties,'' and are the same for all classes. Current standards require

``normal color vision'' for first-class and the ability to distinguish

aviation signal colors for second- and third-class applicants. [FAR

Standards: Current Secs. 67.13(b), 67.15(b), and 67.17(b); Proposed

Secs. 67.103(c), 67.203(c), and 67.303(c)]

6. The current first-class standard pertaining to pathological

conditions of the eye or adnexa that interfere or that may reasonably

be expected to interfere with proper function is substituted in both

the second- and third-class standards for the current standards which

specify, respectively, ``no pathology of the eye'' and ``no serious

pathology of the eye.'' [FAR Standards: Current Secs. 67.15(b) and

67.17(b); Proposed Secs. 67.203(e) and 67.303(d)]

7. The ``whispered voice test'' for hearing is deleted for all

classes. Substituted are a conversational voice test using both ears at

6 feet; an audiometric word (speech) discrimination test to a score of

at least 70 percent obtained in one ear or in a sound field

environment; or pure tone audiometry according to a table of acceptable

thresholds (ANSI 1969). The amended standards for hearing are the same

for all classes. [FAR Standards: Current Secs. 67.13(c), 67.15(c), and

67.17(c); Proposed Secs. 67.105(a), 67.205(a), and 67.305(a)]

8. The standards pertaining to the ear, nose, mouth, pharynx, and

larynx are revised to more general terms and related to flying and

speech communication. Specific references to the mastoid and eardrum

are deleted. The current standard, ``No disturbance in equilibrium,''

is changed to, ``No ear disease or condition manifested by, or that may

reasonably be expected to be manifested by, vertigo or a disturbance of

equilibrium.'' The amended standards are the same for all classes. [FAR

Standards: Current Secs. 67.13(c), 67.15(c), and 67.17(c); Proposed

Secs. 67.105(b), 67.205(b), and 67.305(b)]

9. ``Psychosis,'' as used in the proposed regulation, refers to ``a

mental disorder in which the individual has manifested psychotic

symptoms or to a mental disorder in which an individual may reasonably

be expected to manifest psychotic symptoms.'' This alleviates some of

the problems in interpreting the regulations created by changes in

nomenclature and classification of mental conditions found in the

Diagnostic and Statistical Manual of Mental Disorders, 3rd edition (DSM

III). [FAR Standards: Current Secs. 67.13(d), 67.15(d), and 67.17(d);

Proposed Secs. 67.107(a), 67.207(a), and 67.307(a)]

10. Substance dependence and substance abuse are defined and

specified as disqualifying medical conditions. Substance dependence is

disqualifying unless there is clinical evidence, satisfactory to the

Federal Air Surgeon, of recovery, including sustained total abstinence

from alcohol for not less than the preceding 2 years in the case of

alcohol dependence. In the case of other substance dependence, recovery

would include sustained total abstinence from that substance for not

less than the preceding 5 years. Substance abuse, in the case of

alcohol within the preceding 2 years and in the case of other

substances within the preceding 5 years, is disqualifying. Alcohol

dependence and alcohol abuse are included in the terms ``substance

dependence'' and ``substance abuse'', respectively. [FAR Standards:

Current Secs. 67.13(d), 67.15(d), and 67.17(d); Proposed

Secs. 67.107(a) and (b), 67.207(a) and (b), and 67.307(a) and (b)]

11. ``Bipolar disorder'' is added as a specifically disqualifying

condition. This corrects a regulatory problem created by the change in

nomenclature contained in DSM III. [FAR Standards: Current (None);

Proposed Secs. 67.107(a), 67.207(a), and 67.307(a)]

12. The general mental standard is amended to add the word

``other'' before ``mental.'' The proposed revised standard reads, ``No

other personality disorder, neurosis, or other mental condition * *

*.'' [FAR Standards: Current Secs. 67.13(d), 67.15(d), and 67.17(d);

Proposed Secs. 67.107(c), 67.207(c), and 67.307(c)]

13. ``A single seizure,'' and ``A transient loss of control of

nervous system function(s) without satisfactory medical explanation of

the cause,'' are added as specifically disqualifying neurologic

conditions. [FAR Standards: Current (None); Proposed Secs. 67.109(a),

67.209(a), and 67.309(a)]

14. The word ``seizure,'' is substituted for ``convulsive.'' [FAR

Standards: Current Secs. 67.13(d), 67.15(d), and 67.17(d); Proposed

Secs. 67.109(b), 67.209(b), and 67.309(b)]

15. ``Cardiac valve replacement,'' ``permanent cardiac pacemaker

implantation,'' and ``heart replacement'' are added as specifically

disqualifying cardiovascular conditions for all classes of

certification. [FAR Standards: Current Secs. 67.13(e), 67.15(e), and

67.17(e); Proposed Secs. 67.111(a), 67.211(a), and 67.311(a)]

16. A requirement is added whereby all applicants for second-class

airman medical certificates will be required to have a routine resting

electrocardiogram (ECG) at the first application after reaching age 35

and every 2 years after reaching age 40. An ECG requirement currently

exists for first-class applicants; however, first-class applicants must

have an annual ECG after reaching age 40. There is no requirement added

for third-class. [FAR Standards: Current Sec. 67.13(e); Proposed

Secs. 67.111(d) and 67.211(d)]

17. The current table of age-related maximum blood pressure

readings for applicants for first-class certificates and the reference

to ``circulatory efficiency'' are deleted, and a requirement that

average blood pressure while sitting not exceed 150/95 millimeters of

mercury is added for applicants of all classes. A medical assessment is

specified for all applicants who need or use antihypertensive

medication to control blood pressure. [FAR Standards: Current

Sec. 67.13(e); Proposed Secs. 67.111(b), 67.211(b), and 67.311(b)]

18. For first-class applicants only, a total blood cholesterol

determination after reaching age 50 is added. A cholesterol of 300

milligrams per deciliter or more may require further evaluation

although the applicant, if otherwise eligible, is issued a medical

certificate pending the results. [FAR Standard: Current (None);

Proposed Sec. 67.111(f)]

19. The use of anticoagulant medication is made specifically

disqualifying for applicants of all classes. [FAR Standards: Current

(None); Proposed Secs. 67.111(c), 67.211(c), and 67.311(c)]

20. Current Sec. 67.19 of the FAR, Special Issue of Medical

Certificates, is rewritten [Proposed FAR Standard: Sec. 67.401(a)] to

provide for, at the discretion of the Federal Air Surgeon, an

``Authorization for Special Issuance of Medical Certificate''

(Authorization), valid for a specified period of time. An individual

who does not meet the published standards of part 67 of the FAR may be

issued a medical certificate of the appropriate class if he or she

possesses a valid Authorization. The duration of any certificate issued

in accordance with proposed Sec. 67.401 of the FAR is for the period

specified at the time of its issuance or until withdrawal of the

Authorization upon which it is based. A new Authorization is required

after its expiration, and the applicant must show again that airman

duties can be performed without endangering air commerce.

Proposed FAR Standard, Sec. 67.401(b) also provides for a Statement

of Demonstrated Ability (SODA) instead of an Authorization. The SODA

will be issued to applicants whose disqualifying conditions are static

or nonprogressive and who have been found capable of performing airman

duties without endangering air commerce. The SODA authorizes an

aviation medical examiner to issue a certificate if the applicant is

otherwise eligible.

Proposed Sec. 67.401(e) retains the language of current

Sec. 67.19(c) regarding consideration of the freedom of a private pilot

to accept reasonable risks to his or her own person or property that

are not acceptable in the exercise of commercial or airline transport

pilot privileges, and consideration at the same time of the need to

protect the safety of persons and property in other aircraft and on the

ground.

Proposed Sec. 67.401(f) adds language that explicitly provides that

the Federal Air Surgeon may withdraw the Authorization or SODA. An

Authorization or SODA may be withdrawn at any time for (1) adverse

change in medical condition, (2) failure to comply with its provisions,

(3) potential endangerment of public safety, (4) failure to provide

medical information, or (5) the making or causing to be made of a

fraudulent or intentionally false statement or an incorrect statement

in support of a request for an Authorization or SODA or in any entry in

any logbook, record or report that is kept, made, or used to show

compliance with any requirement for an Authorization or SODA.

Proposed Sec. 67.401(i) allows a person to request that the Federal

Air Surgeon review a decision to withdraw an Authorization or SODA. The

request for a review would have to be made within 60 days of the

service or mailing of the letter withdrawing the Authorization or SODA.

The proposed review procedures would be on an expedited basis and would

provide an affected holder of an Authorization or SODA a full

opportunity to respond to a withdrawal by submitting supporting medical

evidence.

21. Proposed Sec. 67.403 amends current Sec. 67.20 to provide for

denial of an airman medical certificate if the application for airman

medical certificate is falsified. Though this consequence is implied,

the current regulation specifically provides only for revocation or

suspension of certificates. Additionally, Sec. 67.403 proposes to deny

or withdraw any Authorization or SODA where information provided to

obtain it is false, whether the statement was knowingly false or

unknowingly incorrect. Finally, Sec. 67.403(c) proposes that the making

of an unknowingly incorrect statement on an application for an airman

medical certificate or on a request for an Authorization or SODA is a

basis for denial, revocation, withdrawal, or suspension of an airman

medical certificate and the denial or withdrawal of an Authorization or

SODA. The making of an unknowingly incorrect statement is not a basis

for revocation or suspension of other types of certificates or ratings

issued under the FAR.

22. A new Sec. 67.415 of the FAR is proposed to provide that the

holder of any medical certificate that is suspended or revoked shall,

upon the Administrator's request, return it to the Administrator. The

FAA practice always has been to request return of the certificate in

such circumstances.

23. Where appropriate, changes are made to eliminate gender-

specific pronouns, to replace ``applicant'' with ``person,'' to use

current position titles and addresses, to correct spelling and improve

syntax, and to adjust section and sub-section references.

Summary of Proposed Amendments to Part 61

Section 61.3(c) of the FAR provides, with some exceptions, that no

person may serve as pilot in command or in any other capacity as a

required pilot flight crewmember unless that person has in his or her

personal possession an appropriate current medical certificate issued

under part 67 of the FAR. The medical standards for issuing first-,

second-, and third-class medical certificates are set forth in current

Secs. 67.13, 67.15, and 67.17, respectively.

Section 61.23 identifies the duration of validity and privileges of

each class of medical certificate. Currently, a first-class medical

certificate is valid for 6 months for operations requiring an airline

transport pilot certificate, 12 months for operations requiring only a

commercial pilot certificate, and 24 months for operations requiring

only a private, recreational, or student pilot certificate. A second-

class medical certificate is valid for 12 months for operations

requiring a commercial pilot or an air traffic control tower operator

certificate and for 24 months for operations requiring only a private,

recreational, or student pilot certificate. A third-class medical

certificate currently is valid for 24 months for operations requiring a

private, recreational, or student pilot certificate.

Using the John Hopkins University analysis (raw data originated

from the FAA), airman certification data, and annualized pilot exposure

data, a decision model was prepared for the FAA that determined the

best age-specific duration plan for the third-class medical certificate

population. We determined that the best plan would provide for maximum

regulatory relief without public safety decrement. For further

discussion of duration analysis, see this docket's copy of the

regulatory evaluation at pages 25-26, 58-64, and 77-80.

Using the model and the decision criteria previously discussed, the

FAA proposes to lengthen the validity period of third-class airman

medical certificates for most persons under the age of 40. Persons

under age 40 would be required to undergo a physical examination every

3 years for a third-class medical certificate. Third-class medical

certificates for persons age 40 but less than age 70 would continue to

be valid for 2 years. Persons age 70 and older would be required to

undergo a physical examination every year when applying for a third-

class medical certificate.

These ages and examination periods were selected because they will

allow no significant increase in undetected pathology between required

examinations. Regulatory and economic relief can be provided without a

significant effect on aviation safety.

The FAA has determined that the frequency of routine examinations

can be reduced in the case of younger airmen who are less likely to

suffer medical disability and who have undergone an initial examination

and certification prior to first solo flight. Those individuals

manifesting conditions that represent a risk to safety will be denied

certification or, after individual evaluation, will be restricted in

their flying activities or examined more thoroughly and frequently, or

both. Those individuals who meet the published medical standards but

whose conditions require more frequent scrutiny will, under the new

amendment, be issued medical certificates with a validity of 2 years

rather than the longer period which they may otherwise be granted. With

routine medical examination frequency increasing with age as proposed,

aviation safety will be maintained.

Both the AMA report and the Hopkins' analysis confirm the greater

incidence of medical pathology in older persons. FAA analysis also

confirms that the incident of accidents generally increase with an

increase in age. It is prudent, therefore, to leave the current routine

periodic examination requirement unchanged for persons age 40 but less

than age 70 and to increase the frequency of examination for persons

age 70 and older.

All third-class airman medical certificates or third-class

privileges of a first- or second-class medical certificate issued prior

to the effective date of a final rule will remain valid for 2 years

from the date of issuance unless the validity period has been otherwise

limited by the FAA. The period of validity for all third-class airman

medical certificates or third-class privileges of a first- or second-

class medical certificate issued on or after the date of a final rule

will be calculated according to the provisions of the final rule unless

the validity period has been otherwise limited by the FAA.

Because of the increased public responsibilities associated with

commercial pilot privileges, the FAA does not plan at this time to

change the frequency of examinations for first- or second-class medical

certificates for operations requiring an airline transport pilot,

commercial pilot, or air traffic control tower operator certificate.

Similarly, the agency does not plan now to revise the validity period

of student pilot certificates, now 2 years as set forth in Sec. 61.19,

though these are usually issued in combination with the third-class

medical certificate. A student pilot whose student pilot certificate

has expired but whose third-class medical certificate remains valid,

may obtain a new student pilot certificate from an FAA operations

inspector as provided in Sec. 61.85(b).

Section 61.53 of the FAR provides that: ``No person may act as

pilot in command, or in any other capacity as a required pilot flight

crewmember while he [or she] has a known medical deficiency, or

increase of a known medical deficiency, that would make him [or her]

unable to meet the requirements for his [or her] current medical

certificate.'' This amendment does not change Sec. 61.53, and the FAA

continues to require airmen to comply with that rule. In reducing the

frequency of required periodic contacts with knowledgeable health

professionals, self-monitoring and personal attention to health become

a more important part of the individual airman's responsibility for

flight safety. This notice also proposes to amend Sec. 61.39 to require

that applicants must possess at least a third-class medical certificate

or the third-class privileges of a first- or second-class medical

certificate valid under proposed Sec. 61.23 in order to be eligible for

a flight test for a certificate, or an aircraft or instrument rating.

The proposal amends Sec. 69.39 to coincide with the duration changes in

Sec. 61.23, as discussed above.

As noted above, the FAA developed its proposal through review of

the literature, survey of the medical practices of the Department of

Defense, analysis of National Transportation Safety Board (NTSB)

accident data and its own aeromedical certification data, consideration

of the data developed by the Johns Hopkins University, and in

consideration of the part 67 proposal announced in this notice. The

proposed examination spacing represents the agency's view of an optimum

schedule in terms of estimated detectable pathology in the airman

population and of the burden of required examinations.

No change in the scope of required examinations was proposed by

Notice 82-15, Duration of Medical Certificates. Where an applicant for

medical certification demonstrates by history or by findings that

additional or more detailed medical evaluation is required, current

regulations permit the FAA to obtain it. The routine examination used

for many years has proven adequate for the identification of those

airmen who should be further evaluated yet places only minimum burden

on that majority of persons who can be immediately certificated.

Nevertheless, the FAA announced and conducted a complete review of the

standards for airman medical certification (47 FR 16298, April 15, 1982

and 47 FR 30795; July 15, 1982), and examination scope was one object

of the review. The larger part of this notice announces proposals

related to standards and administrative procedures for airman medical

certification.

History of Medical Standards

Airman medical standards have been in effect for many years. The

1938 Code of Federal Regulations (14 CFR parts 20 and 21, 1938) under

the authority of the Air Commerce Act contained minimum requirements

for the physical condition of airmen. The early rules did not provide

for the issuance of airman medical certificates. However, they did

require that an appropriate physical examination be given before a

pilot could be tested for a pilot certificate. In 1942, a system for

the issuance of medical certificates was adopted that provided for the

issuance of first-, second-, and third-class medical certificates.

Discretion in the issuance of medical certificates has always been

a feature of the FAA medical certification system. Over the years this

feature has been modified but the basic provision for special issuance

of a medical certificate to a person who does not meet the required

medical standards has remained. To be granted a special issuance, an

airman has had to demonstrate by operational experience, flight

testing, special practical evaluation, or a special medical evaluation

that he or she can carry out the appropriate airman duties without

endangering public safety during the prescribed time period of the

medical certificate.

A number of specific changes to the medical standards took effect

in 1959. Electrocardiographic examination was required of first-class

certificate applicants. The ECG is to demonstrate the absence of

myocardial infarction and to identify other cardiovascular conditions.

A second amendment provided for additional medical standards related to

a person's general physical condition and nervous system. These

revisions were based primarily on a study conducted by the Flight

Safety Foundation, Inc. (FSF). The study proposed that the existing

certification criteria be expanded to cover the following specific

medical conditions:

(1) An established diagnosis of diabetes requiring insulin or other

hypoglycemic treatment agents;

(2) A history of myocardial infarction or other evidence of

coronary artery disease; and,

(3) A history of an established diagnosis of psychosis, severe

psychoneurosis, severe personality abnormality, epilepsy, chronic

alcoholism or drug addiction.

The FSF position was that the existence of any of the above

conditions was an appropriate basis for disqualification for any class

of medical certificate. The FSF based its recommendation on the belief,

at that time, that medical prognostication for these conditions was too

imprecise to provide assurance that these conditions would not

interfere with the safe piloting of an aircraft. The FSF found that the

likelihood of an occurrence of a partially or totally incapacitating

state directly related to these conditions was so great that an airman

with one of these conditions posed a potential hazard to flight safety.

As a result of the FSF's recommendations, the procedures were amended

to prohibit the granting of special issuances to airmen with these

conditions. The Federal Aviation Act of 1958, however, provided for the

granting of exemptions by the Administrator. In 1960, the FAA specified

that the existing general exemption procedures applied to the medical

standards.

Rapid developments in medical knowledge about the disqualifying

conditions and the development of improved techniques for prediction of

their risk for incapacitation led the FAA shortly afterwards to grant

exemptions, with appropriate limitations, to many persons with these

conditions. Though exemptions were available, requests from individuals

with severe manifestations of some conditions were denied.

In 1971, the authority to grant or deny petitions for exemption

from part 67 was delegated to the Federal Air Surgeon (Amendment 11-11;

36 FR 3462; February 25, 1971). This revision was designed to reduce

administrative processing time and lower costs for the FAA in the

granting of exemptions. The FAA granted over 3,000 medical exemptions

in the ensuing years. Overall, the safety record of airmen who were

granted exemptions has been at least as good as that of the general

population of airmen who hold medical certificates issued under the

medical standards.

In 1982, the FAA amended part 67 in several areas (47 FR 16298;

April 15, 1982). First, any disqualifying condition which previously

required a formal petition for exemption was permitted to be considered

for certification through special issuance procedures. Second, the

prerequisite agency administrative review and decision process leading

to eligibility for NTSB review of denial actions was streamlined.

Third, authority was delegated to the Federal Air Surgeon to place

functional limitations on medical certificates. Fourth, Sec. 67.19 was

amended to state that the Federal Air Surgeon, in granting special

issuances to applicants for private pilot certificates, considers the

freedom of these applicants to accept reasonable risks to their person

or property that are not acceptable in the exercise of commercial or

airline transport privileges, and at the same time, considers the need

to protect the safety of persons and property in other aircraft and on

the ground. Fifth, clarifying interim cardiovascular standards were

issued. Sixth, the alcoholism standard was revised to conform to the

Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and

Rehabilitation Act of 1970. In addition to the amendments to part 67,

the preamble to the 1982 final rule announced that in accordance with

Executive Order 12291, Federal Regulations, the FAA would undertake an

overall review of the medical standards in part 67. This total and

comprehensive review was described as a major rulemaking effort that

would involve obtaining the views of the medical profession and all

other interested parties and result in significant revision of part 67.

Reference

Review of Part 67 of the Federal Air Regulations and the Medical

Certification of Civilian Airmen; Engelberg, A.L., Doege, T.C.;

American Medical Association, under contract to DOT (DTFA01-83-C-

20066); March 1986.

This document is available from the National Technical Information

Service, 5285 Port Royal Rd., Springfield, VA 22161 (accession numbers

AD A166 464, Volume I ($31), and AD A166 465, Volume II ($53). There is

also a handling charge of $3 for purchase by wire or mail. A synopsis

of the 750-page, 2-volume report was published in the Journal of the

American Medical Association (JAMA Vol. 255, No. 12, pp. 1589-1599) on

March 26, 1986, and is available at many libraries and has been placed

in Docket No. 23190.

Current Requirements--Medical Certification of Airmen

Part 67 of the FAR provides for the issuance of three classes of

medical certificates. A first-class medical certificate is required to

exercise the privileges of an airline transport pilot certificate.

Second- and third-class medical certificates are needed to exercise the

privileges of commercial and private pilot certificates, respectively.

An applicant who is found to meet the appropriate medical

standards, based on a medical examination and an evaluation of the

applicant's history and condition, is entitled to a medical certificate

without restrictions or limitations other than the prescribed

limitation as to its duration. These medical standards are currently

set forth in Secs. 67.13, 67.15, and 67.17 (14 CFR part 67).

An applicant for a medical certificate who is unable to meet the

standards in Secs. 67.13, 67.15, or 67.17 may, nevertheless, be issued

a medical certificate. Procedures for granting special issuances or

exemptions have always been available, and, thus, the standards have

never been ``absolutely disqualifying,'' in the sense that

certification is permanently denied all who do not meet the standards.

Under Sec. 67.19, ``Special issue of medical certificates,'' at the

discretion of the Federal Air Surgeon, acting on behalf of the

Administrator under Sec. 67.25 of the FAR, a special flight test,

practical test, or medical evaluation may be conducted to determine

that, notwithstanding the applicant's inability to meet the applicable

medical standard, airman duties can be performed, with appropriate

limitations or conditions, without endangering public safety. If this

determination can be made, a medical certificate may be issued with

appropriate limitations to ensure safety.

Discussion of the Proposal

The FAA proposes to amend part 67 to incorporate additions and

changes in the specific medical standards and scope of examination and

in the administrative procedures pertaining to airman medical

certification. The FAA also proposes to recodify and partly reorganize

part 67 to improve readers' accessibility to specific standards and

procedural requirements. Additional changes are proposed to improve

syntax and correct errors. Section and sub-section references are

adjusted as necessary to reflect additions, deletions, and

reorganization. Because the proposed medical standards are not meant to

be exhaustive in naming all medical conditions that are disqualifying,

the word ``includes'' rather than the word ``are'' is used in each

section of the medical standards. Disqualifying medical conditions are

not limited to those representative conditions listed in the proposed

standards. Medical conditions may be identified during an examination

which are related to a specific medical category of a section in the

proposed standards but are not specifically named in the standards

(e.g., respiratory malignancy). These medical conditions would be

considered under the General Medical Condition section of the medical

standards.

The proposal is based on the FAA's review of part 67, on the FAA's

judgment regarding the AMA Report recommendations, and on public

comment relevant to those recommendations and to the standards

generally. The following discussion of the proposal presents under each

subject heading a discussion of the current rule, the AMA

recommendations, and the proposed rule. Also included in this preamble

is a response to the comments received on the review of part 67 (Docket

No. 23190).

Distant Visual Acuity

The current standards for applicants for first- or second-class

airman medical certificates require that the uncorrected distant visual

acuity be not poorer than 20/100 and the corrected acuity not poorer

than 20/20 in each eye, separately. Applicants for third-class

certificates are required to meet a standard of distant visual acuity

of 20/50 or better in each eye, separately, without correction; or, if

poorer than 20/50, a corrected distant visual acuity of 20/30. For

third-class airman medical certification there is no standard for

minimum acceptable uncorrected distant visual acuity.

The FAA practice for many years has been to grant any class

certificate requested, regardless of uncorrected distant acuity, if the

required minimum vision is present or achieved through conventional

corrective lenses (spectacles or contact lenses), there is no evidence

of significant eye pathology, and the person is otherwise eligible. For

first- and second-class certification, this has been accomplished

through the special issuance process.

Thousands of airmen exercising airline transport pilot, commercial

pilot, private pilot, student pilot, and air traffic control tower

operator certificates have demonstrated their ability to safely perform

their jobs while using corrective lenses for distant visual acuity that

is poorer than 20/100 in each eye.

The AMA Report recognizes that the uncorrected distant visual

acuity standards for first- and second-class certification may be too

stringent and recommends that they be changed from 20/100 to 20/200

without offering a rationale for the specific recommendation of 20/200.

The FAA notes that this recommended standard is consistent, in part,

with the standards of the International Civil Aviation Organization

(ICAO).

In response to the AMA recommendation, in mid-1986, the agency

simplified the procedure for special issuance of certification in cases

where the applicant for a first- or second-class certificate

demonstrates uncorrected distant vision worse than 20/100 but not worse

than 20/200. AME's were given permission to evaluate applicants without

further referral to eye specialists or to the agency for decision. In

the absence of significant eye pathology, the AME may, after telephone

coordination with the agency, issue any class certificate. Individuals

whose distant vision is poorer than 20/200 can be granted certification

only by the FAA, after evaluation by an eye specialist. The FAA has

found through experience that safety is not adversely affected by

permitting medical certification at any level of uncorrected acuity.

Little, if any, disqualifying eye pathology is found through the

special evaluations of applicants whose vision corrects to acceptable

levels, and AME's are able to identify those whose findings suggest the

need for further examination by specialists. Therefore, the FAA

proposes under Secs. 67.103(a) and 67.203(a) the deletion of the

current uncorrected acuity standard for first- and second-class

certification, thereby administratively simplifying the certification

process and reducing costs to airmen and to the agency. The FAA

intends, however, to retain the current requirement for first- and

second-class certification that distant visual acuity be, or correct

to, not poorer than 20/20 in each eye separately.

For third-class certification the FAA proposes under Sec. 67.303(a)

that the standard be amended to require a distant visual acuity of not

poorer than 20/40 in each eye, separately, with or without correction.

This amendment eliminates the confusing current minimum acuity standard

(20/30 if corrective lenses are used and 20/50 if not used) and is

consistent with safety and with the standards commonly used by state

automobile driver licensing authorities. It also reflects the ICAO

standards for private pilots, and it includes the AMA Report

recommendation for minimum distant visual acuity without correction.

Near Visual Acuity

The current near visual acuity standard for first-class medical

certification is expressed as ``* * * at least v=1.00 at 18 inches with

each eye separately, with or without corrective glasses.'' The near

visual acuity standard for second-class medical certification is based

on the ability to pass a test showing that the applicant can read

official aeronautical maps. Currently the rules for third-class medical

certification have no near visual acuity requirements.

The AMA Report recommends several revisions to the near visual

acuity standards. The AMA Report points out that the current vision

terminology of first-class medical certification is antiquated and

unfamiliar to most AME's and ophthalmologists. The AMA also notes that

the Near Vision Acuity Test Card, FAA Form 8500-1, contains letters

that are to be used at 16 inches while the current standards are

established for 18 inches.

The AMA Report recommends the same near visual acuity standards for

all three classes of medical certification: a near vision of 20/40,

Snellen equivalent, at 16 inches in each eye separately, with or

without corrective lenses. In addition, the AMA Report recommends, at

age 50 or older, a near vision standard of 20/40, Snellen equivalent,

at both 16 inches and 32 inches in each eye separately, with or without

corrective lenses.

Additional requirements are imposed after age 50 because, with age,

the eye loses the ability to accommodate for close viewing distances, a

condition called ``presbyopia.'' The AMA Report states:

It is important while piloting to be able to see clearly at

close distances, as when looking at maps, and at intermediate

distances, as when viewing the instrument panel. This is especially

important in night flying. Diminished intermediate visual acuity due

to presbyopia in an individual 50 years of age or older may be

further compromised by bifocal correction. Trifocal or progressive

power lenses may be necessary for clear vision at distance,

intermediate, and near.

The AMA Report recommends that the appropriate necessary corrective

lenses must be worn while exercising the privileges of the certificate.

The proposed rule at Secs. 67.103(b) and 67.203(b) follows the AMA

Report recommendations except that a standard for intermediate visual

acuity is not proposed for third-class medical certification (see

proposed Sec. 67.303(b)). Also, the proposed rule would require only

that the corrective lenses be available while exercising the privileges

of the certificate.

The FAA is not proposing an intermediate visual acuity standard for

third-class certification in recognition of the lower level of

responsibility inherent in noncommercial flight operations.

The proposal does not require that corrective lenses for near or

intermediate visual acuity be worn during all flight operations because

this is a matter better left to the discretion of the pilot. FAA

practice and the FAR currently permit airmen to exercise their

certificates when any required corrective lenses for near vision are in

their possession. This permits, at the airman's option, use of separate

near and distance spectacles; contact lenses for distance with the

addition of spectacles for near; unifocal contact lenses that correct

for both near and distance; bifocal spectacles; or continuously

variable focus spectacles. If the airman requires correction only for

near vision, spectacles, half-spectacles, or bifocal spectacles without

power in the distance portion may be used.

From among these options, an airman should be able to choose his or

her method of visual correction while piloting an aircraft. A

requirement that all airmen wear their correction for near vision while

flying would significantly and, in the absence of demonstrated

problems, unnecessarily limit their choice of visual aids. The FAA has

no evidence that significant operational problems are occurring with

the use of corrective lenses for near vision. Therefore, the proposed

requirement for corrected intermediate vision in older airmen can be

met through possession of additional spectacles of the appropriate

power or by use of trifocal lenses or lenses of continuously variable

focus, as desired.

Color Vision

The current standards for first-class medical certification require

``normal color vision'' (Sec. 67.13(b)(3)); second- and third-class

certification require ``ability to distinguish aviation signal red,

aviation signal green, and white.'' (Secs. 67.15(b)(5) and

67.17(b)(3)).

In current practice, applicants for certification are tested by use

of standard pseudoisochromatic plates or by other approved devices. A

passing score defines the applicant as not color deficient. Failure

indicates a color deficiency and requires that any certificate issued

be limited, prohibiting flight at night or by color signal control.

This limitation can, however, be removed through the successful

completion of a practical signal light test or of a medical flight

test, as appropriate for the class certificate sought and the level of

aviation experience of the applicant.

Airmen are routinely granted second- or third-class medical

certificates without restriction if they pass the signal light test.

When they have the experience required for an airline transport pilot

certificate and pass the medical flight test, first-class certification

is granted. An experienced airman rarely fails a medical flight test

given for deficient color vision.

Safety is further enhanced by the thorough training and testing

given airmen seeking authorization to pilot new aircraft. Through use

of actual aircraft or of simulators, instructors, check airmen, and

flight inspectors have an opportunity to identify and, if necessary,

recommend restrictions for those individuals who encounter difficulty

with color.

The AMA Report states:

* * * the hazard to aviation safety of anomalous color vision is not

clear. No studies have shown that color deficiency has been a direct

cause of accidents. On the other hand, color is an important

constituent of aircraft devices such as instrument panel gauges and

warning lights, and of airport landmarks, such as beacons and runway

lights.

The AMA Report recommends that testing for color vision remain part of

the routine periodic examination of airmen. The suggested standards

include the retention of ``normal color vision for first-class

certification and ``ability to distinguish aviation signal red,

aviation signal green, and white'' for third-class certification. The

AMA Report suggests, however, that the standard for second-class

certification be changed to that for first-class. The AMA Report notes

an increasing use of color in instrument displays for advanced aircraft

but less frequent use of colored signal lights in today's flight

environment. Despite these diverging trends and the absence of accident

data, prudence dictates some continued concern for the color perception

of airmen.

The FAA, therefore, proposes at Secs. 67.103(c), 67.203(c), and

67.303(c) that testing at the time of the periodic medical examination

be continued as recommended, but that the standard for all classes of

certification be, ``Ability to perceive those colors necessary for the

safe performance of airman duties.'' The standard is consistent with

that of the ICAO and reflects the agency's experience and practice for

many years. Tests, instructions, and scoring criteria are provided to

AME's in the ``Guide for Aviation Medical Examiners.''

Certification relative to deficient color vision ultimately is

based on performance. It is appropriate, therefore, that the standard

be related to the job requirement and that it be the same for each

class of medical certificate.

Other Pathology of the Eye

The current standard is worded differently for each class of

certification but without significant difference of meaning. In

accordance with the AMA recommendations, therefore, revision is made to

correct the spelling of the plural word ``adnexa'' and to provide for

the same standard for all classes of certification, at proposed

Secs. 67.103(e), 67.203(e), and 67.303(d).

Eye Fusion

This standard, which applies only to first- and second-class

certification, is revised to correct spelling and to eliminate gender-

specific pronouns. No substantive revisions are proposed for this

standard. (See proposed Secs. 67.103(f) and 67.203(f)).

Intraocular Pressure

The AMA Report recommends for all three classes of certification

the measurement of intraocular pressure after the age of 40 to identify

glaucoma. The basis for this recommendation is that glaucoma may appear

in two forms. One, closed-angle glaucoma, is acute, painful, and

potentially impairing; the other, open-angle glaucoma, is subtle,

painless, and progressive. Either form can be destructive to vision.

Since, in many cases, open-angle glaucoma is not noticed by the

individual until after permanent changes in visual fields have

occurred, a search for it should be a part of any routine health

maintenance examination.

Current regulations have no standard for intraocular pressure,

however, and the FAA is not proposing standards at this time. While the

recommendations of the AMA Report suggest that everyone might benefit

from regular measurement of intraocular pressure, the risk to flight

safety appears minimal in comparison to the cost and difficulty of

testing.

Hearing

Current standards for hearing are as follows: (1) for first-class

medical certification the person must be able to hear the whispered

voice at 20 feet with each ear separately or demonstrate a hearing

acuity of at least 50 percent of normal in each ear as shown by a

standard audiometer; (2) for second-class certification, the person

must be able to hear the whispered voice at 8 feet in each ear

separately; and (3) for third-class certification, the person must be

able to hear the whispered voice at 3 feet in one ear. The use of the

whispered voice has raised questions of accuracy and validity in the

aviation environment. Pure tone audiometry is considered a more

scientific and accepted method for determining hearing capabilities and

for documenting changes in that capability over a period of time. The

present procedure, however, has served well in enabling AME's to

identify for referral and evaluation those individuals whose hearing

acuity is less than normal.

Testing accomplished by the AME serves as a screen to identify

those individuals who should receive more specialized initial and

periodic future evaluations. Almost all hearing-impaired applicants,

however, receive special issuance of a certificate after documentation

of their condition. Many undergo practical testing to determine their

functional aviation capabilities. In the absence of other significant

pathologic conditions, the certification decision regarding hearing

relates only to the individual's ability to safely exercise airman

privileges. Medical flight tests are used frequently for this

determination, and the subject may use hearing aids, if necessary.

Though an airman may regularly use a hearing aid for activities not

involving flight, the normal aircraft communication equipment may serve

as well, and the agency does not, in such cases, mandate the wearing of

an aid. Special issuance is possible, especially for applicants for

third-class medical certification, in the presence of total deafness.

Restrictions on the exercise of airman privileges are applied to

maintain safety in cases of total or functionally significant deafness,

and agency experience demonstrates that these practices have been

successful and appropriate.

The AMA Report recommends that speech discrimination be the basic

screening examination used for certification for all three classes. If

sound field or speech testing audiometry equipment is unavailable, pure

tone audiometry is offered as an alternative. Speech testing would be

accomplished either binaurally or monaurally, while pure tone

audiometry would apply a ``better ear'' and ``poorer ear'' standard.

The AMA Report suggests individual consideration when an applicant

fails the standard tests.

The FAA agrees with the AMA Report that the standards for hearing

and for testing should be the same for all classes of medical

certification.

However, it is unlikely that equipment appropriate for speech

discrimination testing, as proposed by the AMA Report, will be

available to all AME's. In keeping with the intention of the AMA Report

and in the interest of cost, availability, simplicity, and functional

adequacy, the FAA believes and, therefore, proposes at Secs. 67.105(a),

67.205(a), and 67.305(a) that the basic screening test administered to

all applicants be a spoken voice test. This test is included as part of

Hearing Requirement No. 1 and Hearing Requirement No. 2, Chapter 6.--

Medical Requirements, Personnel Licensing, International Standards and

Recommended Practices, Annex 1 to the Convention on International Civil

Aviation, ICAO. It has been implemented in many countries and is easily

described and administered. The conversational voice test is not

inconsistent with the AMA Report emphasis on speech discrimination. The

proposed standards would require that a person be able (1) to hear an

average conversational voice in a quiet room, using both ears, at a

distance of 6 feet; (2) understand speech by audiometric speech

discrimination testing to a score of at least 70 percent obtained in

one ear or in a sound field environment; or (3) provide acceptable

results of pure tone audiometric testing in accordance with a table

that is provided in the rule.

Audiometric speech discrimination or pure tone audiometric testing

are proposed as alternatives or for the further evaluation of

individuals who show reduced hearing acuity in the conversational voice

test. The proposed standard would apply to the examination of

applicants without use of their hearing aids. Need for these devices to

meet the standard suggests that a more detailed evaluation is

appropriate before certification, and that special issuance with

periodic reevaluation may be necessary.

Ear, Nose, Throat, and Equilibrium

In addition to hearing (discussed above), current ear, nose,

throat, and equilibrium standards specify: no acute or chronic disease

of the middle or internal ear; no disease of the mastoid; no unhealed

perforation of the eardrum; no disease or malformation that would

interfere with or be aggravated by flying; and no disturbance in

equilibrium.

The AMA Report recommends, for all three classes, a change of the

standard to specify, ``No acute or chronic disease of the middle or

internal ear that will cause acute paroxysms or unpredictable attacks

of vertigo.'' Also, the AMA Report recommends an additional standard

that specifies, ``No disease or malformation of the oral cavity,

pharynx, or larynx that would interfere with clear and effective speech

communication.'' All other standards in the current rule would be

deleted.

For the most part, the proposed rule at Secs. 67.105(b), 67.205(b),

and 67.305(b) follows the AMA Report recommendations. It requires that

there be no ``disease or condition of the middle or internal ear, nose,

oral cavity, pharynx, or larynx'' that will interfere with or be

aggravated by flying or that will interfere with clear and effective

speech communication. In addition, in the proposed rule at

Secs. 67.105(c), 67.205(c), and 67.305(c) there may be no disease or

condition that may involve vertigo or a disturbance of equilibrium.

Current standards reflect specific concerns about infections of the

ear and mastoid and the damage caused by such infections to the ear

drum and middle ear. The proposed standards more generally and properly

address diseases, or conditions of the ear, nose, or throat that may

interfere with speech communication or equilibrium, factors that are

important for safety.

Mental

Mental disorders may adversely affect judgment and behavior in ways

that create potential hazards in aviation. The current standards for

all three classes of airman medical certification, therefore, list

certain psychiatric disorders for which medical certification would be

denied. The list was derived from the recommendations made by the

Flight Safety Foundation in 1959. These disorders are considered to

constitute a definite hazard to safety in flight when determined to be

present in an airman by established medical history or by clinical

diagnosis. As listed in the current regulations, any of the following

disorders is a cause for denial: (1) a personality disorder that

manifests itself in overt acts; (2) a psychosis; (3) alcoholism; and

(4) drug dependence. In addition, the current standards provide for

denial of medical certification in the presence of any ``other

personality disorder, neurosis, or mental condition that the Federal

Air Surgeon finds makes the applicant unable to safely perform the

duties or exercise the privileges of the airman certificate that he

holds or for which he is applying; or may reasonably be expected,

within two years after the finding, to make him unable to perform those

duties or exercise those privileges.''

The mental standards have been well accepted by the public and by

the medical community as practical and effective. However, with

publication of the authoritative reference, Diagnostic and Statistical

Manual of Mental Disorders, Third Edition (DSM III), changes in the

diagnostic terminology and classification of mental disorders have

caused some confusion. Major illnesses, previously included in the

category of ``psychosis,'' are separately described in the DSM III and

are, therefore, no longer considered by some others as covered under

the term ``psychosis'' in the FAR. Since these conditions are of

concern in the context of airman medical certification and flight

safety, the agency must amend the mental standards to clarify the

position of the FAA.

The AMA Report recommends amendment of the regulations to include a

more extensive and specific list of disqualifying mental disorders:

substance abuse or dependence; schizophrenic disorders; paranoid

disorders; psychotic disorders; major affective disorders (including

bipolar disorders and depression); anxiety disorders; dissociative

disorders; impulse disorders; disorders first evident in infancy,

childhood, and adolescence; and organic brain syndrome.

The proposed rule at Secs. 67.107 (a) through (c), 67.207 (a)

through (c), and 67.307 (a) through (c) would include all of these

disorders but would not specifically list them. The current and

proposed mental standard lists a psychosis as a disqualifying disorder.

The proposed standard states that ``psychosis'' refers to ``a mental

disorder in which the individual has manifested psychotic symptoms or

to a mental disorder in which an individual may reasonably be expected

to manifest psychotic symptoms.'' In this way, two types of persons

would be disqualified under this standard: those who have manifested

psychotic symptoms; and those who have not had psychotic symptoms but

whose mental condition is one in which psychotic symptoms may

reasonably be expected to develop. Psychotic symptoms are characterized

by a failure to maintain adequate contact with reality. The failure to

maintain adequate contact with reality results in or may reasonably be

expected to result in the impairment of judgment, including bizarre,

grossly disorganized behavior; out of control behavior; delusions; or

hallucinations. ``Psychosis'' would include schizophrenic disorders,

paranoid disorders, and other disorders such as mood disorders, that

sometimes manifest psychotic symptoms. Also included would be such

conditions as schizotypal and borderline personality disorders. Other

disqualifying disorders listed in the AMA Report that are not

specifically listed in the proposed rule, such as anxiety disorders and

impulse disorders, may be disqualifying under the general mental

provisions of the regulations as they are now, depending on the

severity of the disorders. The particular circumstances of each

individual history and medical condition are considered by the FAA in

determining whether such history or condition is disqualifying.

The FAA also proposes, as recommended in the AMA Report, that

bipolar disorder be added to the list of disqualifying conditions.

Previously called manic depressive psychosis, this common, major

affective disorder now is separately classified by DSM III and may

include individuals who have manifested only mania. Bipolar disorder is

not specifically referenced in current part 67. In consideration of

potential risk to flight safety, individuals with this diagnosis are

rarely granted certification. Those few individuals who are determined

to be eligible for certification through the special issuance

provisions of the FAR must be followed closely for relapse and

recurrence of symptoms. By including the new terminology, the standards

will clearly reflect the agency's concern about this disorder.

(Discussion of how a proposed disqualifying condition may affect a

current medical certificate appears under ``Additional Standards for

Disqualification.'')

Substance Abuse/Dependence

Additional proposed changes in the mental standards for airmen are

influenced by DSM III nomenclature for conditions involving dependence

on or abuse of alcohol, drugs, or other chemical substances. Current

regulations list as disqualifying ``alcoholism'' and ``drug

dependence.'' The AMA Report points out that DSM III eliminates the

term ``alcoholism'' and substitutes the diagnosis of ``substance

dependence'' and ``substance abuse.'' As disqualifying conditions, the

AMA Report recommends ``substance abuse, substance dependence and

related substance use disorders, including but not limited to those

associated with alcohol; barbiturates; other sedative/hypnotics; muscle

relaxants; anxiolytics; opioids; central nervous system stimulants such

as cocaine and amphetamines; and hallucinogens such as phencyclidine,

cannabis, and volatile solvents and gases.''

The proposed rule differs from the AMA recommendations in that (1)

``barbiturates'' are not specified separately since they would be

included with ``sedatives and hypnotics;'' (2) the phrase ``and

similarly acting sympathomimetics'' would be added to the grouping of

``cocaine'' and ``amphetamines;'' and (3) ``phencyclidine or similarly

acting arylcyclohexylamines,'' ``cannabis,'' and ``volatile solvents

and gases'' are listed separately rather than grouped under

``hallucinogens.'' Additionally, the phrase ``related substance use

disorders,'' as proposed, but not defined in the AMA Report, is not

included in this proposal.

The proposed standard defines ``substance dependence'' and

``substance abuse.'' A medical history or clinical diagnosis of

``substance dependence'' would disqualify a person for a medical

certificate under the standards unless there is evidence of recovery

satisfactory to the Federal Air Surgeon. The proposed changes also are

intended to provide specific regulatory medical standards for excluding

from aviation a person who, though not substance dependent, has abused

alcohol within the preceding 2 years or other substances within the

preceding 5 years. These proposed standards respond to the AMA Report

as well as to national concerns about substance abuse. These standards

would enhance the agency's ability to examine and to exclude, where

medically appropriate, those airmen who have abused a substance within

the time frames stated above or who have a medical history or a

clinical diagnosis of substance dependence. The proposed mental

standard retains, however, current language that permits medical

certification under the standards upon presentation of acceptable

evidence of recovery and a specified period of abstinence in the case

of alcohol dependence. The proposed rule provides that clinical

evidence of recovery would include sustained total abstinence from

alcohol for not less than the preceding 2 years in the case of alcohol

dependence, and in the case of other substance dependence, sustained

total abstinence from the substance for not less than the preceding 5

years. The time periods for sustained total abstinence are based on the

AMA recommendations. Other factors considered in determining recovery

include the natural history and severity of the problem; the period of

satisfactory recovery since manifestation of the problem; any

treatment, as well as any continuing requirements for treatment, and

its nature; any current or recent psychiatric symptoms, aberrant

behavior, or psychiatric or other medical findings; the need for or use

of chemical agents; any personality traits or other recognized factors

involving the risk of future recurrence of the problem or the risk of

other adverse events; the period of the person's abstinence from the

substance or substances; the number of times treatment was sought and

relapse occurred; the quality of the final treatment effort; the

presence of residual medical complications, especially neurologic

manifestations; progress in marital, social, vocational, and

educational areas, as appropriate, since rehabilitation began;

commitment to rehabilitation by virtue of continuing contacts with

social or professional agencies, or both, and their opinions and

recommendations; and the findings of recent psychiatric and psychologic

evaluations, if appropriate.

The proposed definition of substance abuse includes two criteria

(the first relates to alcohol, the second to other substances) that

state a person would be disqualified if he or she demonstrated

recurrent use of a substance in situations in which that use was

physically hazardous. At least one of the uses would have to have taken

place within the preceding 2 years in the case of alcohol or 5 years in

the case of other substances. Under this criterion, use in physically

hazardous situations need not involve the same substance or substances.

A third criterion states that a person who used a prohibited drug

as that term is defined in part 121, appendix I of the FAR would be

disqualified. The prohibited drug use would have to have taken place

within the preceding 5 years. ``Prohibited drugs'' as defined in the

FAR do not include all substances; however, ``substances'' as defined

in this proposal do include all prohibited drugs. Alcohol, for example,

is a substance which may be abused but is not a prohibited drug as that

term is defined under appendix I of part 121.

A positive drug test result for a prohibited drug is one type of

evidence of use. The FAA recognizes that the probative value of a drug

test result varies depending on several factors, including the type of

test, circumstances under which the test was conducted, and other

corroborative evidence of drug use. The FAA considers a positive drug

test conducted under any rule or internal program of the Department of

Transportation (such as the FAA program required by Secs. 121.457 and

135.251 or any other Administration within DOT) to be compelling proof

of the use of a prohibited drug for which the drug test was positive.

With respect to positive drug tests other than those conducted

under rules or internal programs of the Department of Transportation,

the FAA would evaluate such test results and the surrounding

circumstances on a case-by-case basis to determine the weight to be

accorded them. If one of these tests is positive for substance use, the

individual could be disqualified under the criteria used in the

definition of substance abuse or substance dependence.

A fourth substance abuse criterion states that an individual is

medically disqualified if he or she misused a substance that is found

by the Federal Air Surgeon to make the person unable to safely perform

the duties or exercise the privileges of the airman certificate applied

for or held; or may reasonably be expected, within 2 years after the

finding, to make the person unable to perform those duties or exercise

those privileges. The finding of the Federal Air Surgeon is based on

the case history and appropriate, qualified medical judgment. Again, as

in the two previous criteria the misuse must have taken place within

the preceding 2 years in the case of alcohol or 5 years in the case of

other substances.

As with the current regulation, certification before completion of

the 2- or 5-year abstinence/recovery period is possible under the

special issuance provisions of the FAR if an individual evaluation

demonstrates that the applicant is able to perform airman duties

without endangering public safety.

Neurological Conditions

Current regulations on neurological conditions list as

disqualifying for all three classes anyone with a history or clinical

diagnosis of epilepsy or disturbance of consciousness without

satisfactory medical explanation of cause. Nor may a person have any

other convulsive disorder, disturbance of consciousness, or

neurological condition that the Federal Air Surgeon finds makes the

person unable to perform airman privileges safely, or may reasonably be

expected, within 2 years after the finding to make the airman unable to

perform airman privileges.

A detailed discussion of neurological conditions, their evaluation,

and prognosis is provided within the AMA Report. Additional information

and recommendations are contained in ``Neurological and Neurosurgical

Conditions Associated with Aviation Safety,'' a major report prepared

in 1979 by representatives of the American Academy of Neurology and the

American Association of Neurological Surgeons through an earlier

contract between the FAA and the AMA. Neither report proposes detailed,

objective criteria and tests that could be included in the standards

and by which medical certification could be determined. They discuss

the medical techniques now available for evaluation of individual

airmen and the significance of the results obtained from their use.

Both reports emphasize the significance of seizure disorders. The

few changes to the standards suggested by the AMA Report are proposed

by the FAA at Secs. 67.109, 67.209, and 67.309, for all three classes

of airman medical certificates and include the addition of ``a single

seizure'' to the list of disqualifying conditions; the use of

``seizure'' rather than ``convulsive'' to describe disorders that may

be found disqualifying by the Federal Air Surgeon; and the addition of

a ``transient loss of control of nervous system function(s) without

satisfactory explanation of the cause'' as a specific basis for

disqualification. This last proposed addition clarifies the agency's

aeromedical concern about such events whether or not they are

characterized as disturbances of consciousness. (Discussion of how a

proposed disqualifying condition may affect a current medical

certificate appears under ``Additional Standards for

Disqualification.'')

Other neurological conditions described in the AMA Report, though

of significance in questions of aeromedical certification, are not

proposed as separate standards. The proposed regulatory provisions

provide an adequate medical basis for assuring safety.

The AMA Report recommended that an abbreviated mental examination

of four questions be included in each airman medical certification

examination. If one or more responses are incorrect, the Mini-Mental

Status Examination of Folstein, Folstein and McHugh (Folstein) would be

given. The FAA studied the feasibility of the AMA Report's

recommendation. It found that neither the AMA-recommended test nor the

test by Folstein provides a useful screening device, alone or in

combination, for airman neurological status. There was an unacceptable

incidence of false negatives. Additionally, neither test, alone or in

combination, provides predictors of any skills known to be relevant to

piloting.

Cardiovascular Conditions

To meet its statutory responsibility to ensure public safety, on

May 17, 1982 (47 FR 16298; April 15, 1982), the FAA amended part 67 of

the FAR in part to clarify the cardiovascular standards. This change

codified FAA policy that individuals with a history of coronary heart

disease not be medically certificated for the exercise of airman

privileges under Secs. 67.13, 67.15, or 67.17. These individuals would

continue to be certificated through the discretionary special issuance

procedures after a separate determination that their disease no longer

represents a risk to aviation safety. During that rulemaking procedure,

a number of commenters expressed the belief that the cardiovascular

standards for medical certification should be relaxed. Commenters also

suggested that those standards be revised to set forth more detailed,

objective criteria and tests by which medical certification could be

determined, and a group of concerned pilots submitted a petition for

rulemaking (to be discussed later in this document) that was intended

to accomplish such a revision. Many commenters contended that the

standards failed to take into account the advances in medicine that had

occurred since part 67 was issued. The FAA announced that these issues

would be addressed in its review of part 67.

Accordingly, the FAA specifically asked the committee of

consultants assembled by the AMA to review the cardiovascular standards

in light of recent advances and current concepts in cardiovascular

medicine. Further, the FAA asked the physicians to develop suggestions

for inclusion of diagnostic and prognostic techniques in the standards,

if appropriate and feasible. The final AMA Report, however, indicates

that the group could not establish, in the standards, qualifications

for medical certification. Instead, the AMA Report suggests general

retention of the current cardiovascular standards and format with

additions to further improve their utility for ensuring aviation

safety. In the presence of known cardiovascular disease, certification

decisions still would require professional evaluation of multiple

medical factors rather than verification of the results of a test

specified in the published standards. The individual airman who fails

to meet the published standards would continue to be considered in

accordance with the discretionary special issuance provisions.

The AMA Report does recommend a number of changes. Additional

cardiac conditions are suggested for inclusion in the standards as

rendering an airman unqualified for certification; revised standards

for acceptable blood pressure are given; maximum levels of blood

cholesterol are proposed for some commercial airmen; and routine

periodic electrocardiography for all airmen is recommended. Rather than

changes to the standards, the AMA Report emphasizes the need for

careful evaluation of all applicants prior to certification. Where

individuals are found either to have cardiovascular disease or to have

factors or findings indicative of increased risk, more exhaustive

evaluations are suggested before certification can be granted and

before periodic renewal of certification. Recommendations for these

evaluations are included in the AMA Report and are generally consistent

with long-standing FAA practice.

Coronary Heart Disease

The FAA proposes that the present standards pertaining to coronary

heart disease and its manifestations remain unchanged. As amended in

1982, these standards are clear and have provided a firm medical basis

for denying airman privileges to individuals with significant, active

coronary heart disease who might endanger public safety. This condition

precludes routine airman medical certification because it is a

documented cause of in-flight pilot incapacitation, and it is

progressive in nature.

The FAA will continue to evaluate airmen who fail to meet this

standard to determine their eligibility for a discretionary special

issuance of medical certification. Certification will be based upon

acceptable evidence that the individual has recovered and that his or

her anatomic and physiologic cardiac status would justify the

subsequent exercise of airman privileges. Appropriate functional

limitations of airman privileges may be applied, and periodic follow-up

medical reevaluations may be required to detect any relapse or

progression of disease. This procedure protects the public while

providing a means of relief for those individuals whose heart disease

has stabilized sufficiently to pose an acceptable risk. Since adoption

of the amendments in 1982, an increasing number of airmen have been

found eligible and granted certification.

Additional Standards for Disqualification

The FAA also proposes additions to the standards in proposed

paragraphs (a) (4), (5), and (6) of Secs. 67.111, 67.211, and 67.311,

providing that a history or clinical diagnosis of cardiac valve

replacement, implantation of a permanent cardiac pacemaker, or heart

replacement would make the subject person unqualified for certification

under the standards. These amendments are consistent with the AMA

Report and the opinions of agency consultants and reflect the serious

nature of each of the conditions. Among the agency's concerns are

failure of prosthetic heart valves, pacemaker malfunction or

progression of underlying disease that has required artificial cardiac

pacing, organ rejection, or the complications of immunosuppression.

While the FAA may determine that an airman with a history or clinical

diagnosis of any of these conditions may be granted a discretionary

special issuance of certification, such history would preclude

certification until specialized medical evaluation confirms adequate

recovery and function and the absence of significant risk in terms of

the aviation environment. Where special issuance of certification is

granted, the regulations will provide for periodic medical

reevaluations, if appropriate, for subsequent certification.

Under the proposed medical standards, a small number of airmen, who

currently hold certificates as a result of an order of the NTSB, would

become disqualified from further medical certification because of the

addition of specifically disqualifying medical conditions. These airmen

had been denied medical certification by the FAA under a current

general medical standard. Under the general medical standards, an

individual is denied certification by the FAA when he or she has a

condition which the Federal Air Surgeon finds may reasonably be

expected to make the individual unable to safely perform pilot duties.

For example, the FAA has denied certification to airmen who have had

cardiac valve replacement and the NTSB has ordered certification in

some of these cases. Under the proposed standards a medical history of

cardiac valve replacement would be specifically disqualifying and those

airmen would no longer be entitled to certification. It is expected,

however, that the possible certification of such individuals would be

reviewed under the Federal Air Surgeon's special issuance authority

once the FAA evaluates the case and is satisfied with the airman's

condition since the NTSB ordered certification. Such a disposition of

these cases would be consistent with the FAA's practice after the 1982

amendment of the cardiovascular standards rendered several airmen

disqualified whose certification under the old medical standards had

been ordered by the NTSB.

Other AMA Recommendations

The AMA Report also suggests that certain other cardiac diagnoses

be added to the standards as specific disqualifications. FAA

certification experience, however, has not indicated a need for

regulatory change in cases of cardiomyopathy, congenital heart disease,

valvular heart disease or murmurs, pericarditis, or disturbances of

heart rhythm or conduction. The agency agrees with the AMA Report that

these conditions pose a potential risk but has found that the existing

standards and procedures provide adequate opportunity for

identification and evaluation of the affected airmen and a regulatory

basis for denial of airman privileges, if appropriate.

Electrocardiography

Current standards require that applicants for first-class medical

certificates submit a resting, 12-lead ECG at the time of their first

examination after reaching age 35 and, annually, after reaching age 40.

They must show by these ECG's, ``an absence of myocardial infarction.''

An ECG made within the 90 days before an examination for a first-class

medical certificate is accepted as meeting the requirement. There now

is no routine requirement for submission of ECG's by applicants for

second- or third-class medical certificates.

The AMA Report notes that it is well established that up to 20

percent of myocardial infarctions (``heart attacks'') fail to produce

symptoms that bring a person to a physician. The resting ECG often

shows evidence of a prior myocardial infarction and patterns of

anatomic change and other abnormalities that are also associated with

an increased risk of coronary artery disease. The AMA Report adds that

many of the most common alterations of cardiac conduction seen on the

routine ECG are not associated with symptoms or with easily discerned

physical findings. Yet, each of these electrocardiographic findings

causes special concerns regarding medical certification and may result

in recommendations for additional assessment.

The AMA Cardiovascular Committee, in recognition of these facts,

recommended that the requirement for electrocardiography be modified in

an effort to increase the assurance that significant cardiac disease in

pilots will be detected. The committee suggested that, in addition to

the current requirement for first-class certificates, an ECG be made on

all applicants for medical certification at the time they first apply.

These ECG's would serve as a valuable medical baseline for future

comparison. Further, the committee recommended that an ECG be made on

applicants for second-class medical certificates at ages 35 and 40

years and every 2 years thereafter, and on applicants for third-class

certificates at age 40 years and every 6 years thereafter. The

committee also suggested that the standard be modified to include the

agency's concern for any clinically significant electrocardiographic

abnormality rather than the current limited specification of myocardial

infarction alone.

In proposed Sec. 67.211(d), all applicants for second-class airman

medical certification would be required to submit ECG's at the first

examination after reaching age 35 and, biennially, after reaching age

40. There is reciprocity between the first- and second-class

cardiovascular standards in satisfying the ``after reaching the 35th

birthday'' and the ``after reaching the 40th birthday'' ECG

requirements. For example, an application with an ECG that satisfies

the ``age 35'' ECG requirement for first-class medical certification

also satisfies the ``age 35'' ECG requirement of an application for

second-class medical certification and vice versa. In the case of the

``after reaching the 40th birthday'' ECG requirement, however, the time

provisions of Secs. 67.111(d)(3) and 67.211(d)(3), as discussed below,

are also required for reciprocity.

The proposed time provision for the ``after reaching the 40th

birthday'' periodic ECG for first-class medical certification requires

that an applicant submit an ECG with the application unless, within the

preceding 9 months, an ECG was provided as part of an application for

medical certification. That is, if an applicant has submitted an ECG as

part of an application for airman medical certification within 9 months

of the current application, the applicant does not have to submit

another ECG for the current application. Thus, after reaching the 40th

birthday, a person who maintains a first-class medical certificate

would be required to have an ECG at alternate applications or

approximately every year. In a few cases, it could be 1 year and 3

months between first-class ECG's. The time provision for the ``after

reaching the 40th birthday'' periodic ECG for second-class medical

certification is the preceding 15 months. An applicant maintaining a

second-class medical certificate would be required to have an ECG at

alternate applications or approximately every 2 years. In a few cases,

it could be 2 years and 3 months between ECG's. The proposed

requirement for first-class medical certification allows more leeway

than the current rule. An applicant with a first-class medical

certificate could wait up to 9 months and the ECG of the previous

application for a first-class medical certificate would meet the

requirement for the succeeding application for a first-class medical

certificate. An applicant with a second-class medical certificate could

wait up to 15 months and the ECG of the second-class medical

certificate would meet the requirement for the succeeding application

for second-class medical certification. No ECG requirement is being

proposed for third-class medical certification.

To ensure the currency of an ECG, the FAA proposes in

Secs. 67.111(e) and 67.211(e) that if a person is required to submit an

ECG as part of an application for medical certification, it must be

dated no earlier than 60 days before the date of the application it is

to accompany and must be performed and transmitted according to

acceptable standards and techniques. Of course, there is no requirement

to submit an ECG with a current application for medical certification

if a previous ECG submitted as a part of an application for medical

certification can satisfy any current ECG requirement. Sixty days is a

longer period than the 30 days recommended by the AMA Report but

represents a reduction from the 90 days now permitted. The agency

recognizes that many ECG's are provided by employers or through private

physicians other than the AME, and a reasonable period, such as that

proposed, is appropriate for the airman's convenience. Finally, the FAA

did not propose a baseline ECG be performed for either first- or

second-class medical certificate applicants because it had a negative

cost analysis and the FAA considers the ECG after age 35 to serve as an

adequate baseline ECG.

The FAA also proposes to amend the wording of the standard to

require that the affected person ``demonstrate an absence of myocardial

infarction and other clinically significant abnormality on

electrocardiographic examination.'' The FAA will continue to require

electrocardiography or other appropriate evaluations for any airman

whose medical history or findings suggest it.

Blood Pressure

The current medical standard pertaining to blood pressure applies

only for first-class medical certificates. Depending on the person's

age and the scope of the examination accomplished, blood pressures from

140 to 170 mm Hg pressure, systolic, and 88 to 100 mm Hg pressure,

diastolic, are permitted. In practice, 170 mm Hg systolic and 100 mm Hg

diastolic have been considered the maximum allowable pressures for all

applicants for second- and third-class certificates. The ICAO standard

provides only that the blood pressure of all airmen be ``within normal

limits.''

In addition, Sec. 67.13(e)(5) of the FAR provides that, ``if an

applicant is at least 40 years of age, he must show a degree of

circulatory efficiency that is compatible with the safe operation of

aircraft at high altitudes.''

It is rare for an applicant for certification to manifest

hypertension (high blood pressure) at the level of the current standard

or above. Current and accepted medical practice for several years has

reflected knowledge of the adverse effects of even mild elevations of

blood pressure and treatment is prescribed for most individuals at

levels of blood pressure much lower than the FAA standard for medical

certification. If any person is taking medication for hypertension, FAA

practice is to consider the condition as coming under the provisions of

present Sec. 67.13(f)(2), General medical condition, of the FAR. This

section directs that the applicant have ``no other organic, functional,

or structural disease, defect, or limitation that the Federal Air

Surgeon finds makes the applicant unable to safely perform the duties

or exercise the privileges of the airman certificate that he holds or

for which he is applying; or may be reasonably expected, within 2 years

after the finding, to make him unable to perform those duties or

exercise those privileges; * * *'' Certification is conditioned on the

findings of a more detailed medical evaluation, including an assessment

of cardiovascular risk factors, the presence or absence of disease of

``target'' organs, the degree of blood pressure control, and of the

medication itself.

The AMA Report recommends that the existing, outmoded standard for

blood pressure be replaced. It suggests a sitting blood pressure

standard of 150 mm Hg pressure, systolic, and 95 mm Hg pressure,

diastolic, for all pilots. It further recommends that the systolic

level never exceed 160 mm Hg, regardless of the diastolic blood

pressure. The AMA Report notes that its recommendations represent a

somewhat less rigid standard for younger airmen and a more rigid

standard for older airmen. Less rigid standards for the younger airmen

are appropriate in terms of safety. For older airmen the more rigid

standards respond to data demonstrating the adverse medical

significance of the high level of blood pressure permitted by the

current standard.

The FAA agrees that the existing standard relating to blood

pressure is outmoded and does not reflect current medical knowledge or

practice. It also finds that current Sec. 67.13(e)(5) is medically

vague and does not serve a useful purpose. Accordingly, it proposes

that the provisions of Sec. 67.13(e) (4) and (5) of the FAR, including

the table, be deleted and replaced by new standards (proposed

Secs. 67.111(b), 67.211(b), and 67.311(b)) applicable to all classes of

medical certificates. It proposes that average blood pressure while

seated not exceed 150 mm Hg, systolic, or 95 mm Hg, diastolic. For ease

of application, the agency will not introduce into the standard the

additional suggestion that the systolic pressure never exceed 160 mm

Hg.

The proposed standard would require more extensive assessment of

airmen who require or use antihypertensive medication. To maintain

first-class certification, the assessment will be required at least at

annual intervals, usually with every other application. For second- and

third-class certification, valid for 1 year and 2 years, respectively,

the assessment will be required with each application. Unless otherwise

determined by the FAA under the special issuance provisions of the FAR,

certificates will be valid for the normal periods and, in most cases,

issued by the designated AME if there are no adverse findings. These

procedures are included in current FAA guidelines.

This proposed amendment would clarify the FAA's concern for the

cardiovascular risk represented by hypertension and the agency's

position that persons who are undergoing therapy for hypertension

should be evaluated to assess the degree of risk. Though these

standards are being codified for the first time, this evaluation does

not represent a new practice.

Cholesterol

Currently no cholesterol standards exist in the regulations. In

consideration of the responsibility for public safety held by airmen

exercising pilot privileges in air transport operations, the FAA has

partially accepted the recommendations of the AMA Report that the level

of blood cholesterol be determined as part of the examination for

medical certification. The Risk Factor Committee of the AMA that

considered risk factors and qualifications for flying suggested that

serum cholesterol and triglyceride levels be determined for all

applicants initially and at 50 years of age. The Cardiovascular

Committee of the AMA, however, recommended that a determination of

serum cholesterol be made only for 50-year old applicants for first-

and second-class medical certificates who exercise airman duties in

single-pilot commercial operations. Both committees recommended further

evaluation if a level greater than 300 milligrams per deciliter (mg/dl)

of total cholesterol is found.

The FAA proposes (proposed Sec. 67.111(f)) that total serum

cholesterol be tested annually as part of the examination of all

applicants for first-class medical certification who have reached their

50th birthday. Unlike a single determination, an annual requirement

will assist the FAA in the identification of adverse trends in

cardiovascular risk factors as airmen age. Applicants whose cholesterol

level is determined to exceed 300 mg/dl would be required to undergo an

additional cardiovascular evaluation to determine if significant

disease is present, but issuance of a medical certificate would not be

withheld solely on the basis of the cholesterol level.

The FAA agrees with the AMA Report and with the National Institutes

of Health regarding the importance of this risk factor for disease and

believes that the additional cost to the holders of first-class airman

medical certificates is justified by the more effective identification

of disease. By limiting this requirement to first-class certificate

holders 50 years of age and older, public benefits are enhanced with

minimum costs by targeting the population having the greatest risk and

greatest public responsibility.

The FAA does not consider feasible the AMA Report recommendation

that the serum cholesterol level requirement be limited to persons who

exercise airman duties in single-pilot commercial operations.

Individual airmen frequently perform in a variety of commercial

operations or change from one type of operation to another. There are

no regulatory controls for limiting applicability of such a requirement

to single-pilot commercial operations.

Hematocrit

Currently no standard exists in the FAA regulations for blood

hematocrit. The AMA Report recommends that all applicants at age 40,

and periodically thereafter, demonstrate a hematocrit within the range

of 32 to 55 percent. The requirement is recommended because the ability

of blood to transport oxygen effectively to tissues is dependent on

adequate hemoglobin concentration and on the ability of blood to

perfuse organs. Abnormalities of this function can result in

incapacitating organ infarcts. Also, a number of significant medical

conditions are often reflected in abnormalities of the blood. Anemias

of various etiology, organ malignancies, polycythemia, lung disease,

hemoglobinopathies, coagulation and thrombotic disorders, hematologic

neoplasia, lymphomas, immunodeficiency syndromes, and other disorders

are included in the conditions that may be discovered through

examination of the blood.

The FAA is not proposing to add new standards for blood hematocrit

testing at this time. Hematocrit testing would impose incremental costs

on applicants for a first-class airman medical certificate and

additional administrative costs on the FAA. While the recommendations

of the AMA Report suggest that hematocrit testing would result in

detection of certain adverse or potentially incapacitating medical

conditions, the risk to flight safety appears minimal in comparison to

the cost of testing. The list of specific conditions that would

disqualify a person is not proposed for inclusion in the FAR because

the conditions are already covered in the general medical standards.

Anticoagulation

Current regulations do not contain specific standards for

anticoagulation. Under the general rules of current paragraphs (f)(2)

(i) and (ii) of Secs. 67.13, 67.15, and 67.17, the FAA has denied

routine certification of persons who require medication for

anticoagulation. The FAA does, however, grant special issuance to a

limited number of airmen who use this type of medication after

extensive evaluations of the conditions requiring anticoagulation, the

stability of the airmen's treatment regimens, and the presence or

absence of adverse side-effects. Periodic reevaluation always is

required for subsequent certification.

The AMA Report recommends denial of routine medical certification

for any person who uses an anticoagulant medication. This

recommendation is consistent with earlier medical reports such as the

report of the Eighth Bethesda Conference of the American College of

Cardiology in 1975, the Report of a Working Party of the Cardiology

Committee of the Royal College of Physicians of London in 1978, The

First United Kingdom Workshop in Aviation Cardiology in 1982, and The

Second United Kingdom Workshop in Aviation Cardiology in 1987, and with

recommendations of some FAA medical consultants. Based on its

experience with airmen who are taking anticoagulant medication, the FAA

believes that some individuals who receive anticoagulant medications

may be granted airman medical certification after careful evaluation of

their specific condition. Such certification represents an exception,

however, and must be accomplished under the special issuance provisions

of the FAR, subject to appropriate, periodic medical reevaluation and

possible restrictions. To clarify this position and to meet the FAA's

statutory responsibility to ensure public safety, the FAA proposes

(proposed Sec. 67.111(c)) to add the use of anticoagulant medication to

those conditions specified in the FAR as disqualifying an individual

for certification. (Discussion of how a proposed disqualifying

condition may affect a current medical certificate appears under

``Additional Standards for Disqualification.'')

Respiratory System

Current regulations do not contain specific standards pertaining to

the respiratory system. The Respiratory System Committee, in its

section of the AMA Report, recommended that all airmen older than 40

years periodically demonstrate the absence of severe lung disease

through spirometry, a simple, non-invasive test available in the

physician's office. The committee stated its concerns for the danger to

public safety represented by airmen with serious pulmonary disease such

as chronic obstructive pulmonary disease (COPD), asthma, pulmonary

fibrosis, infectious diseases of the lung, hypoventilation syndromes,

chronic interstitial lung disease, and disorders of the respiratory

muscles and bony thorax. Both judgment and the ability to perform

complex tasks may be affected adversely by a reduction of oxygen

available to the brain (hypoxia) because of poor pulmonary function,

and acute lung disease can cause hypoxia without warning. Altitude

itself affects pulmonary function, so careful assessment of pulmonary

status is required to prevent incapacitation during flight, according

to the committee's report.

Tests that measure the actual levels of oxygen and carbon dioxide

in the arterial blood are costly and not generally available in the

aviation medical examiner's office. Careful clinical assessment of

respiratory function, including medical history and physical

examination ordinarily are used to separate those applicants requiring

further evaluation of their pulmonary status from those who do not.

The FAA is not proposing to add a new requirement for routine

spirometric testing at this time. Spirometric testing would impose

incremental costs on applicants for all classes of airman medical

certificate and additional administrative costs on the FAA. AME's would

be required to purchase the equipment necessary to perform the

examination. Under current practice, individuals with potentially

serious pulmonary disease are identified through existing procedures

and referred for further evaluation, including spirometric testing, of

their pulmonary status to determine their eligibility for medical

certification.

The AMA Report also recommends specifically disqualifying diseases

and conditions of the respiratory system. These would include severe

lung disease, poorly controlled asthma, sleep disorders, pulmonary

hypertension, pneumothorax, pulmonary emboli, and carcinoma of the

lung. The list of specific conditions that would disqualify a person is

not proposed for inclusion in the FAR because the conditions are

already covered in the general medical standards.

Diabetes

In its discussion of diabetes in the preamble to Amendment 67-11,

the FAA stated that the Federal Air Surgeon would continue to deny

certification to individuals who have an established medical history or

clinical diagnosis of diabetes that is controlled by the use of insulin

or another hypoglycemic drug (47 FR 16298, April 15, 1982). The

preamble further stated, ``If, in the future, information demonstrating

that medical technology has advanced to the point that diabetes can be

controlled without significant risk of incapacitation from hypoglycemia

or other complications becomes available to the FAA, consideration for

special issuance of a medical certificate under Sec. 67.19 will be

possible.''

As part of the review of part 67, the AMA Report made

recommendations concerning individuals seeking medical certification

who have an established history or clinical diagnosis of diabetes that

is controlled by insulin or another hypoglycemic drug. The AMA Report

recommended that persons whose diabetes is adequately controlled with

oral hypoglycemic drugs and who show evidence of stability and freedom

from adverse effects be considered for medical certification with

proper medical monitoring. The Endocrine Committee assembled by the AMA

believes that the likelihood of incapacitation from the effects of

diabetes or its treatment with current oral hypoglycemic drugs, in

those persons medically selected and monitored, is very remote. The AMA

Endocrine Committee recommends that absolute prohibitions of

certification of individuals requiring insulin for control of diabetes

be continued. Informal surveys of agency medical consultants, comments

by interested medical practitioners, and review by the FAA medical

staff indicate general agreement with these findings and

recommendations of the AMA Report. The more widespread use of

technically advanced equipment and procedures has made it possible for

physicians to better select those persons who should be allowed to use,

or continue to use, oral drugs to control their disease. The increased

use of simple equipment and tests for self-monitoring gives the

diabetic and the physician a more accurate and timely picture of a

person's immediate condition as well as his or her ability to control

blood sugar over time.

In view of the current consensus of the medical community, the FAA

has determined that many individuals whose diabetes is without

complications and acceptably controlled by diet and oral drugs, with

appropriate monitoring and other conditions, can perform the duties

authorized by their class of medical certificate without endangering

public safety. Accordingly, though no substantive rule change is

proposed to current requirements in paragraph (f)(1) of Secs. 67.13,

67.15, and 67.17, the Federal Air Surgeon has determined that those

persons who do not meet the medical standard of the FAR because their

diabetes requires oral hypoglycemic drugs will no longer be

categorically denied special issuance of airman medical certification.

In determining eligibility for medical certification under the

special issuance provisions of the FAR, the Federal Air Surgeon

considers the natural history and severity of the problem, the period

of satisfactory recovery since manifestation of the problem, and any

treatment, as well as any continuing requirements for treatment, and

the nature of treatment. For diabetics whose disease is controlled with

oral hypoglycemic agents, additional factors that may be considered

include: the age of onset of diabetes; the documented degree and means

of past and present diabetes control; the presence or absence of

adverse effects, including hypoglycemic episodes; the presence or

absence of other known risk factors; and the individual's willingness

and ability to maintain strict control of his or her condition and

treatment and to cooperate with any monitoring plan required by the

FAA.

Four physicians who served on the AMA Report's Endocrinology

Committee subsequently submitted a letter stating that they

reconsidered their Committee's recommendation on diabetes. The

recommendation of the Endocrine Committee was to continue to disqualify

diabetics who use insulin to control their disease. In their letter,

the four physicians stated that persons on insulin therapy should be

allowed consideration for special issuance certification. Several other

physicians who commented on the AMA Report also supported certification

of persons on insulin therapy.

The issues raised by these commenters pertain to current FAA policy

of not permitting special issuance consideration for persons on insulin

therapy. As recommended by the full AMA Committee, the FAA proposes to

retain this policy but remains open to a change in its policy should

there be any new medical developments. The issue was thoroughly covered

by the full AMA Committee and its recommendation was made after

deliberation and thorough discussion. The contra recommendation of the

four physicians who submitted a letter to the FAA was not subjected to

the same process, nor did their recommendation contain any acceptable

procedure for identifying persons on insulin therapy who could be

safely, reliably, and practically certified through the special

issuance process.

In a related matter, a summary of an American Diabetes Association

(ADA) petition for rulemaking to review FAA rules and policies

regarding individuals with diabetes was recently published in the

Federal Register (56 FR 10383, March 12, 1991). Specifically, the ADA

petitioned the FAA to amend FAR Secs. 67.13, 67.15, 67.17, and 67.19 to

allow individuals with insulin-treated diabetes mellitus to be issued

medical certificates on a case-by-case basis. The ADA further requested

the creation of an FAA-appointed medical task force to develop a

medical protocol capable of permitting meaningful case-by-case review.

Docket No. 26493 was established to receive comments on the ADA

petition. Since the comment period on the ADA petition has closed but

the subject of that petition is directly related to the part 67 review,

additional comments on the diabetes-related issues raised in the ADA

petition may be submitted to the docket of this rulemaking. The FAA may

dispose of the issues raised in the ADA petition through this action at

the final rule stage, or through the issuance of a separate disposition

of the ADA petition.

Musculoskeletal

The Musculoskeletal System Committee of the AMA recommends

standards that would disqualify an applicant for medical certification

because of conditions such as quadriplegia, hemiplegia, hemiparesis,

collagen disease, and vascular disease. The FAA does not propose

specifying these conditions as disqualifying since they are already

covered by current general medical standards (proposed Secs. 67.115,

67.215, and 67.315).

Special Issuance of Medical Certificates

The FAA has used special issuance (waiver) provisions of Sec. 67.19

(proposed Sec. 67.401) for many years to grant airman medical

certification to acceptable applicants who do not meet the published

standards. Prior to 1982, except for applicants for air traffic control

tower operator certificates, this authority was not available for

airmen with histories of certain psychiatric, neurological, cardiac, or

endocrine conditions, and exemptions from the regulations were

required. Beginning in May 1982, however, airmen with a history or

clinical diagnosis of any medical condition could be granted

discretionary medical certification through the special issuance

provisions if it could be determined that, notwithstanding the person's

failure to meet the applicable medical standard, airman duties could be

performed, with appropriate limitations or conditions, without

endangering public safety. Through special issuance provisions, many

airmen have returned to productive aviation careers and others to

private flying after recovery and rehabilitation from serious medical

conditions without adverse impact on public safety.

Consideration for the granting of a special issuance can be

initiated in different ways. Currently, the FAA will often consider an

individual for a special issuance who does not meet the medical

standards under part 67 without a formal request to the agency from the

individual. In some cases an individual who does not meet the medical

standards under part 67 will make a written request to the Federal Air

Surgeon or to his or her authorized representative to be considered for

a grant of a special issuance.

Under current practice, a special issuance letter is issued

advising an airman of the FAA's decision to grant the special issuance

of a medical certificate. The letter describes the provisions and

conditions of a special issuance of medical certification. Based on the

letter and on the individual being otherwise eligible, the agency or

examiner issues a medical certificate to the individual. These

procedures apply for a new application and for an application for

recertification.

Current Sec. 67.19 provides that the Federal Air Surgeon may limit

the duration of a medical certificate issued under that section,

condition the continued effect of a medical certificate on the results

of subsequent medical tests, examinations, or evaluations, impose any

operational limitation needed for safety, or condition the continued

effect of a second- or third-class medical certificate on compliance

with a statement of functional limitations issued to the person in

coordination with the Director of Flight Standards or the Director's

designee. It is implicit in this section that in the interests of

public safety a finding of adverse change in the medical condition of

the holder would result in termination of the validity of the medical

certificate.

The validity of the special issuance letter, however, does not

lapse until the FAA takes some affirmative action to modify or

terminate it. Similarly, once a medical certificate is issued pursuant

to the special issuance provisions, even if the FAA terminates the

special issuance letter, it may be considered that the medical

certificate itself does not lapse until the original date of

expiration, unless it is sooner suspended or revoked under the

provisions of section 609 of the Federal Aviation Act. Long-standing

agency practice in the case of adverse medical change has been to send

the holder a letter terminating the validity of the special issuance of

medical certification and requesting the return of any medical

certificates held.

To ensure that the medical justification for the special issuance

remains valid and the holder of the special issuance undergoes the same

type of periodic reevaluation as the holder of any medical certificate

does, it is proposed that the duration of an Authorization for Special

Issuance of a Medical Certificate (Authorization) will be limited, and

a new request for that Authorization will be required upon expiration.

In addition, when the FAA determines that an Authorization should be

withdrawn, the medical certificate issued pursuant to that

Authorization will also expire, in accordance with proposed

Sec. 67.401(a).

An Authorization is one of two types of special issuances and

covers those medical conditions, such as coronary heart disease, where

the disease is progressive in nature. A Statement of Demonstrated

Ability (SODA) is the second type of special issuance. If a medical

condition, such as the accidental loss of a limb or deficient color

vision is static and nonprogressive, the FAA issues a SODA to those

applicants found able to perform airman duties without endangering

public safety. This document remains valid indefinitely and permits a

designated AME to issue a medical certificate of the specified class if

the holder remains otherwise eligible. In the event of adverse change,

certification is withheld and the person referred to the FAA for a new

determination of eligibility.

Current Sec. 67.19 (proposed Sec. 67.401) refers only to the

special issuance of medical certificates. The FAA proposes to add

specific reference to the two types of special issuance documents: An

Authorization and a SODA. The first document codifies the special

issuance letter currently used to grant and describe the provisions of

a special issuance of medical certification, and the second codifies a

document that has been in use for many years. The proposed change

explicitly connects the duration of any medical certificate issued to

the validity of the document upon which it is based and requires

periodic requests for reissuance.

The FAA also proposes to add language (proposed Sec. 67.401(f))

that explicitly provides that the Federal Air Surgeon may withdraw an

Authorization or SODA when: There is adverse change in the holder's

medical condition; the holder fails to comply with a statement of

functional limitations or operational limitations issued as a condition

of medical certification; the public safety would be endangered by the

holder's exercise of airman privileges; the holder fails to provide

medical information reasonably needed by the Federal Air Surgeon to

determine continued eligibility for certification under the special

issuance provisions; or the holder makes or causes to be made a

fraudulent or false statement or an incorrect statement in support of

his or her request or in any entry in any logbook, record, or report

that is kept, made, or used, to show compliance with any requirement

for an Authorization or SODA.

Proposed Sec. 67.401(i) would allow a person to request a review of

a decision to withdraw an Authorization or SODA. The holder of an

Authorization or SODA that is withdrawn may request, within 60 days

after the service or mailing of a letter of withdrawal, that the

Federal Air Surgeon provide for a review of the decision to withdraw.

The review procedures would provide the holder an opportunity to submit

supporting evidence in his or her behalf, and to otherwise respond to

the decision to withdraw. The proposed procedures and timeframes in

Sec. 67.401(i) are intended to provide an expeditious administrative

review for the benefit of those persons affected by a decision to

withdraw an Authorization or SODA. The public is invited to comment on

the proposed procedures for withdrawal of an Authorization or SODA.

Proposed Sec. 67.401(j) implements the procedure by which the FAA

will convert current special issuances to either Authorizations or

SODA's. All Authorizations will have an expiration date. The date will

coincide with the expiration date of the airman's medical certificate

or a date as stipulated by the Federal Air Surgeon or his or her

authorized representative that relates to any medical test, report, or

examination required as a condition of the special issuance.

Applications, Certificates, Logbooks, Reports, and Records:

Falsification, Reproduction, or Alteration

Section 67.20(a) (proposed Sec. 67.403(a)) of the FAR provides the

regulatory basis for enforcement action when an applicant or airman

falsifies a medical certification document. In current Sec. 67.20(b),

consequences for violating paragraph (a) include suspension or

revocation of all airman, ground instructor, and medical certificates

and ratings held by that person.

Although present paragraph (a)(1) provides explicitly only for

suspension or revocation for fraudulent or intentionally false

statements on any application for a medical certificate, the FAA has

denied the medical certificate applied for in such cases. If the FAA

interpreted the current regulation narrowly, it would have to issue a

medical certificate and then revoke it in cases where the person has

falsified the application. The proposed revision of these requirements

(proposed Sec. 67.403) provides explicitly for denial of an application

for medical certification, as well as for suspension or revocation of

all airman, ground instructor, and medical certificates and ratings

held by that person, if the person makes a fraudulent or intentionally

false statement or entry on the application or other document required

to be kept, made, or used to show compliance with any requirement for

any medical certificate under part 67.

A new paragraph (c) has been added to proposed Sec. 67.403 to allow

the FAA the option of denying, suspending, or revoking an airman

medical certificate if any incorrect statement or entry has been made,

even if the person did not knowingly make the incorrect statement or

entry. Medical certification based on incorrect medical data may be

inappropriate in the light of the true data.

Proposed Sec. 67.403 also prohibits fraudulent or intentionally

false statements or incorrect statements or entries in connection with

any Authorization or SODA. In addition, proposed Sec. 67.401, which

sets out the procedures for Authorizations and SODA's, specifically

lists the making of a fraudulent or intentionally false statement or an

incorrect statement as grounds for withdrawal of an Authorization or

SODA.

Certification Procedures, Applicability, and Medical Examinations

No substantive changes are proposed for present Sec. 67.23 of the

FAR (proposed Sec. 67.405). Current Sec. 67.21 is deleted because it is

unnecessary under the new reorganization.

Delegation of Authority

This section (current Sec. 67.25; proposed Sec. 67.407) would be

amended to substitute the current term ``Manager'' for ``Chief'' in the

delegation of authority to the Manager, Aeromedical Certification

Division, Civil Aeromedical Institute. It also would be amended to add

issuance, renewal, denial, and withdrawal of Authorizations and SODA's

to the authority delegated by the Administrator to the Federal Air

Surgeon.

Denial of Medical Certificate

Current Sec. 67.27 of the FAR (proposed Sec. 67.409), Denial of

Medical Certificate, is proposed for amendment only to substitute

current terminology and the address for the Manager, Aeromedical

Certification Division, and to remove gender-specific pronouns.

Medical Records

The FAA proposes to amend Sec. 67.31 of the FAR (proposed

Sec. 67.413(a)) to change the word ``refuses'' to ``fails'' to make it

clear that there need not be an actual refusal by an applicant or

holder of a medical certificate to furnish requested information to

trigger a suspension, modification, or revocation of a medical

certificate. Failure to provide the requested information is sufficient

cause for the Administrator to act. A new sentence would be added to

this section (Sec. 67.413(b)) to make it clear that submission of

requested information does not automatically lead to issuance of a

medical certificate. A determination by the Federal Air Surgeon that

the person meets applicable medical standards is needed before a

certificate will be issued. The FAA also proposes to remove gender-

specific pronouns and to substitute the more appropriate word,

``physician'' for the word ``doctor.''

Return of Medical Certificates After Suspension or Revocation

Current Sec. 67.27(g) of the FAR provides that the holder of a

medical certificate shall surrender it, upon request of the FAA, if its

issuance is wholly or partly reversed upon reconsideration. Part 61

(Sec. 61.19(f)) provides that the holder of any certificate issued

under that part that is suspended or revoked shall, upon the

Administrator's request, return it to the Administrator. Except for

Sec. 67.27(g), part 67 is silent regarding return of medical

certificates that have been suspended or revoked under the FAR or under

Section 609 of the Federal Aviation Act of 1958 (49 U.S.C. 1422).

Because the retention by an airman of an invalid medical certificate is

not consistent with proper and efficient enforcement of safety

regulations, new Sec. 67.415 is proposed. This amendment would codify

existing practice, and clarify that any airman medical certificate

revoked or suspended under existing authority must be returned on

request of the Administrator.

Related Petition

On July 7, 1981, the Civil Pilots for Regulatory Reform (CPRR)

filed a petition with the FAA Administrator (Docket No. 22054; AVS-81-

520-P). The petition took issue with two aspects of the airman medical

certification process. First, that the cardiovascular standards for

first-, second-, and third-class medical certificates (paragraph (e)(1)

in Secs. 67.13, 67.15, and 67.17; 1981), automatically disqualify an

airman who has an established history or clinical diagnosis of a

myocardial infarction regardless of degree or recency. Second, that the

only means to regain medical certification is dependent on the sole

discretion of the Federal Air Surgeon via an exemption under part 11 of

the FAR.

The CPRR petition proposes to modify a subparagraph of the 1981

cardiovascular standard which reads, ``No established medical history

or clinical diagnosis of myocardial infarction . . .,'' to read, ``No

coronary artery disease that makes the applicant unable to safely

perform the duties or exercise the privileges of the airman certificate

that he holds or for which he is applying; or may reasonably be

expected, within 2 years after the finding, to make him unable to

perform those duties or exercise those privileges; and the findings are

based on the case history and appropriate, qualified, medical judgment

relating to the condition involved.'' The effect of the proposed change

is that a history of coronary artery disease would not, per se,

disqualify an airman.

The CPRR petition also proposes that the standards and tests used

by the Federal Air Surgeon to recertificate pilots who have sustained

infarcts be published in regulatory form in an appendix to part 67, and

that a pilot be granted appeal rights to the NTSB in the event that an

exemption is denied. Furthermore, the CPRR petition proposes that the

medical exemption procedures under part 11 be revised to provide a

``due process'' format for the exemption deliberation under part 11.

The format would include: (a) if the airman petitioner requests

exemption under part 11 because of disqualification under the

cardiovascular standard, the airman is given a complete file, prior to

the exemption panel meeting, of all records, reports and other

documents which the agency plans to consider in the ruling; (b) the

airman may attend and present evidence at the exemption panel meeting;

(c) panel members must record their individual position in the official

record of the meeting; and (d) the agency must construct a record

sufficient to form a basis for review by the courts of appeal under the

arbitrary and capricious standard of review.

FAA Response: The medical standards were revised in 1982 (47 FR

16298; April 15, 1982). The revision eliminated the need for the time

consuming and cumbersome exemption pathway under part 11 for part 67

medical disqualification cases and opened up part 67 medical

disqualification cases (including cardiovascular cases) to special

issuance procedures under Sec. 67.19. Additionally, the 1982 rule

change stated, in the preamble, general and specific criteria that

would be considered in the determination of a cardiovascular special

issuance. The 1982 change considerably reduces the administrative costs

and processing time for special issuance cases.

In regard to the CPRR proposals to change the disqualifying

statement on myocardial infarction and to allow for ``due process'' and

appeal, FAA review of part 67 has not led to such proposals. The

disqualification for myocardial infarction remains in the proposed

rules. However, it is, and would continue to be, possible for an

applicant with a history or diagnosis of myocardial infarction to

receive a medical certificate through the special issuance procedures

if further medical evaluation of the applicant shows that he or she is

able to perform the privileges of an airman certificate without

endangering public safety. Any applicant who has been denied

certification because he or she is unqualified under the cardiovascular

standards is notified of the procedures, standards, and tests required

for special issuance determination. Test results are reviewed and

evaluated by medical specialists. Generally, in difficult cases or

those involving commercial pilots, a panel of cardiovascular

specialists reviews the medical reports and other required

documentation, assesses the risks involved in accordance with its best

medical judgment and advises if it believes a special issuance is

warranted. The procedures provide for a reasoned, objective

determination based on medical facts and judgment. The determination is

not based on a hearing-type procedure in which subjective facts are

weighed. In any case, the proposed rule would allow for the same ``due

process'' as under the present rule.

Discussion of Public Comments

The FAA requested public comments on the review of part 67 in two

separate notices. On July 15, 1982, the FAA announced the review of the

regulations and invited public comment (47 FR 30795). On May 23, 1986,

the FAA announced the availability of the AMA Report and invited public

comment on recommendations in the report (51 FR 19040). A total of 211

comments were received. Comments were submitted by pilots, pilot

organizations, and physicians, including several AME's. Most of the

comments refer to the AMA Report recommendations, only some of which

are proposed in this document for adoption.

The following discussion of comments addresses only the main

medical issues raised by commenters that are relevant to this

rulemaking document. It does not address comments on AMA

recommendations that the FAA did not choose to adopt. Some commenters

recommended changes similar to those recommended in the CPRR petition

and, since the FAA's position on these issues has already been stated,

it is not repeated below. While the following discussion addresses the

main medical issues raised by commenters, it is not intended to be an

exhaustive discussion of all of the comments received and considered by

the FAA.

Comments Received on the Review of Part 67

In response to the first notice, the FAA received 52 comments

providing suggestions for the FAA to consider during its review of part

67.

Twenty commenters, including four physicians, comment on persons

with diabetes. In general, the commenters argue that diabetes is a

disease that is well understood and easily monitored by a personal

physician. Advances in treating diabetes, such as home glucose

monitoring and other tests, provide full control to a pilot of his/her

illness. Several pilots suggest that diabetes is readily containable

with the appropriate medical care, and no significant physical strain

is placed on a diabetic pilot in providing continuous treatment of the

illness.

Four commenters discuss the possible benefits of an

electrocardiogram (ECG) in evaluating a person's medical situation. One

doctor who is also an AME recommends a chest X-ray as a preventive

test.

Another physician explains that there are currently no standards

for risk factors such as cholesterol, cigarette smoking, and blood

pressure. These all have links to heart disease and, as a result,

should be closely examined. Three people, including two physicians,

support closer testing of pilots for signs and effects of alcoholism.

They point out that alcohol abuse is a major cause of aviation

accidents and should, therefore, be tested.

Nineteen people objected to the stringent medical standards for

persons obtaining a third-class medical certificate under Sec. 67.17.

They argue that these strict standards are too rigid for this class of

flyers, who are generally leisure and sports pilots and can not easily

obtain a medical examination.

The Aircraft Owners and Pilots Association (AOPA) submitted a

detailed section by section recommendation for revising part 67 that

was based on recommendations of a medical advisory panel of

distinguished physicians that was convened by AOPA.

FAA Response: The FAA considered all of these comments, including

AOPA's section by section recommendations, during its review of part

67. The FAA's proposed standards and policy on diabetes are discussed

under the proposed rule portions of this preamble. New ECG requirements

are proposed in this notice. Assessment of risk factors such as

cholesterol and blood pressure is included and standards pertaining to

alcoholism have been updated in the proposal.

The proposed rule amends the standards for third-class medical

certificates in light of recent technology and medical knowledge. As

noted in the discussion of the proposed rule, the standards for third-

class medical certificates are less stringent than those for first- and

second-class certificates in recognition of the lower level of

responsibility inherent in noncommercial flight operations.

Comments Received on AMA Report Recommendations

Most commenters were generally opposed to any AMA recommendations

that involved a perceived strengthening of the standards for airman

medical certification. Only eight commenters generally favored the AMA

recommendations, some with suggestions for improving them.

Many of the opposing comments from pilots were based on their

reading of an editorial about the AMA Report which appeared in Flying

magazine (Volume 113, November 1986, page 24) entitled ``What's Up,

Doc?'' While the editorial was factually accurate, it briefly

summarized some of the recommendations and was primarily a subjective

editorial opinion opposing certain recommendations in the AMA Report.

Cost and Safety

The most frequent comment from those who objected to the AMA Report

recommendations is that the recommended changes will result in a

substantial increase in the cost of obtaining a medical certificate and

that there are no accident data to indicate a need for increasing

medical standards and thereby medical certification costs.

FAA Response: The review of part 67 was necessary to ensure that

the standards reflect current medical technology and evolving knowledge

about conditions that could affect a pilot's ability to perform safely.

For the most part, the proposed revisions to part 67 are not a

strengthening of the standards over current regulations and policy.

They represent clarification, codification of policy, and an updating

of the current standards and practices. The proposed rule would make

some standards less stringent, such as the deletion of uncorrected

distant visual acuity requirements and the revised wording of those

requirements pertaining to the eye, ear, nose, pharynx, and larynx. In

other instances, additions to the medical examination requirements such

as the proposed new standards for blood pressure for second- and third-

class medical certification are clearly warranted. The FAA would be

remiss in its responsibility for safety if it ignored medical findings

and advances that can better identify those individuals subject to

incapacitation or deterioration of performance. The estimated costs and

benefits of this proposal are addressed in a Regulatory Evaluation

Summary later in this preamble and more fully in a full regulatory

evaluation which is in the public docket.

Prevention vs. Safety

Several commenters object to statements in the AMA Report that

certain recommendations are based on concepts of preventive medicine.

These commenters say that the FAA's responsibility is to safety rather

than to a system of healthier pilots. According to these commenters,

the purpose of the agency's medical examination is to determine if a

pilot is able to perform safely the privileges of the airman

certificate, not whether the pilot is generally healthy.

FAA Response: The FAA is not proposing to change the primary safety

objective of the medical certification examination. Rather, the

proposed revisions to the standards embody what has been learned in the

last 25 years about medical risk factors. FAA's interest in risk

assessment is directly related to its need to determine at the time of

a medical examination as much objective information as possible on the

medical condition of the person being examined. This information is

directly relevant to FAA's need to determine the likelihood that the

person being examined will remain medically fit for the next 6 months,

or 1 or 2 years, as applicable.

The AMA report is fully consistent with helping the FAA meet its

statutory safety responsibilities. The AMA Report notes that some of

its recommendations include ``risk factor identification items.'' It

further notes:

These items add to the safety factor for which the examination

is designed; they also increase the likelihood that pilots who pay

attention to these risk factors will be able to enjoy flying

aircraft for more years.

The fact that the AMA Report mentions potential long term

preventive health benefits that may accrue to the person being examined

in no way diminishes the importance of the short term health evaluation

benefits that are of primary concern to the FAA.

AMA Contract

Several commenters object to the AMA Report because they believe

the recommendations are in the AMA's self interest. According to these

commenters, any proposed increase in requirements would serve to

increase the cost of the medical examination and thereby the income of

doctors.

FAA Response: In its consideration of the AMA Report, the FAA found

no indication of self-serving motives. The AMA committees which worked

on developing the recommendations were made up of experienced and

respected specialists in each area of medical interest. Each committee

did an in-depth and thorough analysis of the current standards in

relation to advances in medical knowledge and examination techniques

and recommended, as appropriate, optimum standards for safety. The FAA

reviewed and considered these recommendations along with public

comments (many from professionals in the field) and advice from its own

staff. Factors such as pilot performance, aircraft technology, and

cost, in addition to general safety were considered by the FAA in

assessing each AMA recommendation. (A cost benefit analysis appears in

the Regulatory Evaluation portion of this preamble.) The FAA believes

the proposed standards will benefit all airmen as well as the general

public.

FAA Workload

Several commenters express concern that the AMA Report

recommendations, if adopted, would lead to an increase of denials and,

therefore, an increase in requests for certification under the special

issuance provisions of the FAR. This in turn would lead to

certification processing delays.

FAA Response: The FAA does not anticipate that the proposed

standards will significantly increase the internal FAA workload. The

potential for such an increase and the FAA's plans to meet the increase

are discussed more fully in the regulatory evaluation.

Industry Disincentive

Several commenters state that general aviation is presently in

economic trouble and that more stringent medical standards would

discourage more people from becoming general aviation pilots.

FAA Response: The FAA does not agree. The safer the system, the

greater the number of participants and the lower the cost. The FAA

believes that these proposals encourage and support aviation.

Alleged Discrimination Against Older Pilots

Several commenters allege that the AMA recommendations discriminate

against older pilots in favor of younger ones, since many of the tests

recommended become critical for pilots after the age of 40 or 50. Air

transport pilots who commented argue that, if adopted, the

recommendations might prohibit some older and more experienced pilots

from flying. According to these commenters, older pilots represent a

high percentage of the highly competent and seasoned professional

pilots.

FAA Response: Any medical standards necessarily have a greater

effect on older persons since many disorders occur more frequently with

advancing age, especially after age 40. The FAA contracted with Johns

Hopkins University to prepare a detailed statistical analysis of

computerized medical information collected by the FAA from examination

of approximately 31,000 air traffic controllers over a 15-year period.

The study sample was demographically comparable to the private pilot

population and the examinations were similar to airman medical

examinations. The analysis shows that the incidence of pathology

recorded at periodic examinations increases with age; the prevalence of

pathology in individuals over the age of 50 was greater than in those

under the age of 40. The AMA recommendations and the FAA proposed rule

focus on those disorders most likely to result in reduced performance

or to incapacitate a pilot. They provide for more relevant, more

thorough, and more predictive evaluations after age 40 or 50,

particularly for those persons seeking first-class medical

certification. Proposed changes in this category relate to vision;

electrocardiograms; and blood cholesterol determinations. The proposed

standards will permit the identification of risk factors and encourage

pilots to maintain better control over those conditions which

eventually could lead to disqualification. Those AMA recommendations

included in the FAA proposal should serve, in the long term, to

increase the pool of experienced, professional, and medically eligible

pilots.

AME's or Private Physicians

Several commenters raise issues about the role of AME's and the

role of private physicians in the maintenance of a pilot's health. Two

flight instructor pilots state that mistrust exists between pilots and

medical examiners caused by pilots' fear of losing their medical

certification and their careers as pilots. More stringent rules, as

recommended by the AMA, will increase pilots' concerns and mistrust.

Commenters also believe that some of the recommendations concerning

family history, for example, should be the domain of a pilot's personal

physician and that in some instances personal physicians could supply

the information required by the recommended standards.

FAA Response: Both current and proposed standards permit the use of

test results provided by personal physicians, such as ECG's and X-rays.

However, the historical and legal role of the AME as a designee of the

FAA is to conduct a medical examination to determine the fitness of the

pilot to exercise the privileges of his or her certificate without

endangering public safety. The proposed standards in no way are

intended to interfere with or replace a pilot's use of a personal

physician. Experience, however, indicates that the FAA's statutory

responsibility to ensure that an airman is medically fit to perform his

or her duties cannot be delegated to any personal physician. The

proposed changes, however, should not affect the relationship between

pilots and AME's.

Specific Standards

Several commenters object to one or more specific recommendations

in the AMA Report. Objections to cardiovascular and vision standards

are the most frequent. Some of these commenters express concern that

the recommended standards will serve to discourage good health

practices through fear of denial. For example, commenters who objected

to the AMA recommendation for a blood pressure standard particularly

object to the AMA recommendation that an applicant shall have no

established medical history of use of antihypertensive medication

within the last year. Commenters who use antihypertensive medication

said they would either stop taking the medication (which they need) or

be denied.

FAA Response: The proposed standards do not specify that

individuals using antihypertensive medication shall be denied

certification. If antihypertensive medication is used or is needed to

meet the blood pressure requirement, a person may be issued a

certificate only after a current, satisfactory medical assessment,

prescribed by the Federal Air Surgeon. In this case as in some others,

the FAA has not followed the AMA recommendation. However, the comments

indicate a misunderstanding. A medical history of a disqualifying

condition, whatever that condition is, does not necessarily mean that a

person will be denied certification absolutely. It may mean that

additional evaluation may be required before the FAA can determine if

certification is appropriate. This may require additional time and some

expense for additional tests, but, for most of the proposed standards,

the added inconvenience is minimal compared to the improvement in

safety.

Regulatory Evaluation Summary

Introduction

Three requirements pertain to economic impacts of regulatory

changes to the FAR. First, Executive Order 12291 directs Federal

agencies to promulgate new regulations or modify existing regulations

only if the potential benefits to society outweigh the potential costs.

Second, the Regulatory Flexibility Act of 1980 requires agencies to

analyze the economic impact of regulatory changes on small entities.

Finally, the Office of Management and Budget (OMB) directs agencies to

assess the effects of regulatory changes on international trade. In

conducting these analyses, the FAA has determined that this rule:

(1) would generate benefits exceeding costs, and, thus, is not a

major rule as defined by the Executive Order; (2) is significant as

defined in DOT's Policies and Procedures; and (3) would not have a

significant impact on a substantial number of small entities; and (4)

would not have an impact on international trade. These analyses,

available in the docket, are summarized below.

Regulatory Evaluation Summary

The majority of the proposed amendments would have insignificant

attributable costs with respect to the benefits received. This

evaluation does not address the minor proposed amendments such as

changes in syntax, technical corrections, reorganization, updating

medical terminology, or adjustments to cross-references for conformance

purposes.

Furthermore, the evaluation attributes no significant costs or

benefits to several other proposed amendments that would add a specific

disease or medical condition to the list of medical standards. Such

additions do not necessarily constitute a change in the standards.

Current regulations include two open-ended (general) medical standards

that cover:

(1) any other personality disorder, neurosis, or mental condition *

* *, or (2) any other organic, functional, or structural disease,

defect, or limitation * * * that the Federal Air Surgeon finds would

make, or may reasonably be expected to make, the applicant unable to

perform the duties associated with the certificate. Thus, the

applicable medical standards are not limited to those actually listed

in the regulation. As medical knowledge and experience progress, the

Federal Air Surgeon may find a previously unlisted disease or condition

to be grounds for withholding or restricting a medical certificate, so

long as that finding is based on qualified medical judgment.

Under the proposed standards, a small number of airmen who

currently hold certificates as a result of an order of the NTSB would

become disqualified from further medical certification because of the

addition of specifically disqualifying medical conditions. These airmen

were denied medical certification by the FAA under the current general

medical standards. For example, the FAA has denied certification to

airmen who have had cardiac valve replacement and the NTSB has ordered

certification in some of these cases. Under the proposed standards, a

medical history of cardiac valve replacement would be specifically

disqualifying and those airmen would no longer be entitled to

certification. It is expected, however, that certification of the

affected individuals would continue under the Federal Air Surgeon's

special issuance authority once the FAA evaluates the case and is

satisfied that the airman's condition has not worsened since the NTSB

ordered certification. As such, the expected economic impact of the

specifically disqualifying medical conditions would be minor.

Costs and Benefits That Are Not Quantified

Prior to summarizing the evaluation of the substantive proposals,

it is important to note one category of costs and one category of

benefits that have not been quantified in this analysis. The evaluation

does not explicitly quantify the economic consequences to those

individuals who would lose their pilot certificate privileges as a

result of the proposed additional medical tests or standards. Where

such consequences are expected, the evaluation estimates the numbers of

persons who would be denied but does not attribute a cost to those

actions.

It is recognized that the denial of pilot privileges would mean the

loss of a highly valued avocation for some individuals. For others, it

would actually result in the loss of primary livelihood. An accurate

assessment of the economic valuation of the denials that are projected

under this proposed rule is beyond the scope of the evaluation.

At the same time, the evaluation also does not quantify the

overwhelming personal health benefits, external to flight safety, that

would be afforded to those individuals whose medical conditions would

be detected and whose treatment would be enabled by the proposed tests

and standards. On average, third-class medical certificate holders

spend only 0.7 percent of their time flying. The evaluation only

quantifies the direct benefits of the proposed rule to reduced aviation

accidents.

Under existing regulations, the Federal Air Surgeon is charged to

deny a certificate in those cases where a disease or other physical or

mental condition would make, or may be reasonably be expected to make,

the applicant unable to perform the duties associated with the

certificate. Such findings are not capricious, but instead, are based

on the case history of the individual and on appropriate, qualified

medical judgment.

Summary of Quantified Costs and Benefits

Vision Proposals, All Classes

The proposed rule would institute additional vision tests and

standards for all three classes. For first- and second-class applicants

age 50 and older, it would add a new standard (20/40 Snellen) and a new

test for intermediate vision (32 inches). Applicants for third-class

medical certificates would be subject to a new standard (20/40 Snellen)

and a new test for near vision (16 inches).

The projected 10-year (1994-2003) costs of the intermediate vision

proposal for first-class applicants are $1.1 million in primary testing

costs, $1.7 million in follow-up compliance costs (examinations and

glasses) for those persons not meeting the standard, $5,641 in direct

processing costs for the expected 14 additional persons who would be

denied under the provision, totalling $2.8 million, with a 1993 present

value of $2.0 million.

The projected 10-year costs of the intermediate vision proposal for

second-class applicants are $462,887 in primary testing costs, $2.2

million in follow-up compliance costs (examinations and glasses) for

those persons not meeting the standard, and $6,529 in direct processing

costs for the expected 17 additional persons who would be denied under

the provision, totalling $2.7 million, with a 1993 present value of

$1.8 million.

The projected 10-year costs of the near vision proposal for third-

class applicants are $2.8 million in primary testing costs, $1.3

million in follow-up compliance costs (examinations and glasses) for

those persons not meeting the standard, and $131,340 in direct

processing costs for the expected 339 additional persons who would be

denied under the provision, totalling $4.2 million, with a 1993 present

value of $2.9 million. It is emphasized that the denials and costs

associated with the near vision proposal are not wholly attributable to

the proposed amendment. Although this requirement does not exist in

current regulations, it has been in place administratively for some

time. Thus, the associated costs are being, and would continue to be,

incurred without this proposed amendment.

NTSB accident records were investigated for the periods from 1962

through 1989 for commercial flights and from 1982 through 1989 for

general aviation (GA). For these periods, no accident was found where

intermediate or near vision deficiency was specifically determined to

be the cause. As such, the FAA is not able to quantitatively ascribe

the benefits of the three proposed vision amendments based on

historical accident analysis.

Notwithstanding the absence of documented accidents related to

these three proposals, the FAA maintains that such accidents may well

have occurred and could continue to occur in the absence of the

proposed amendments. The NTSB accident analysis system may not document

those cases where a near or intermediate vision problem caused or

contributed to accidents. Examples would include deviations from course

or altitude, inaccurate monitoring of gauges and other avionic

displays, and incorrect setting of aeronautical parameters such as

headings or radio frequencies.

While the extent to which intermediate or near vision problems have

caused such accidents is unknown, it is the FAA's position that: (1)

general aviation pilots require adequate near vision to read charts and

checklists, and (2) commercial pilots require adequate intermediate

vision to properly monitor aircraft instruments. Although this

evaluation is not able to quantify the benefits of the proposed vision

amendments, the FAA holds that the benefits would be significant and

would exceed the expected costs.

Electrocardiogram (ECG), Second-Class

The proposal would add a new requirement whereby applicants for

second-class medical certificates would be required to have a routine

resting ECG at the first application after reaching age 35 and every 2

years after reaching age 40. The projected ten-year costs of the

provision are $25.5 million in primary testing costs, and $1.7 million

of additional testing and processing costs for those persons who would

not meet the standard, including 178 persons who would be denied,

totalling $27.2 million, with a 1993 present value of $19.2 million.

The projected benefits of this provision were based on a review of

the related NTSB accident records. In the absence of this proposal,

commercial pilot, heart-related accidents over the 1994-2003 period are

projected to consist of: 2.64 deaths per year valued at $6.60 million,

.14 serious injuries per year valued at $89,600, .14 minor injuries per

year valued at $322, and 2.06 damaged or destroyed (GA and commercial)

airplanes per year valued at $169,360, totalling $6,859,282 per year.

The projected benefits of this provision over the ten-year study period

are $68.6 million, with a present value of $48.2 million. The FAA holds

that the proposed amendment would meet or exceed the 40 percent

effectiveness level ($19.2 million cost / $48.2 million potential

benefit) necessary to be cost beneficial.

Blood Pressure, Second-Class

The proposal would add a new requirement that the sitting blood

pressure second-class medical certificate applicants not exceed 150/95

millimeters of mercury. The projected ten-year costs of the provision

are $1.8 million in primary testing costs and $0.7 million of

additional testing and processing costs for those persons who would not

meet the standard, including 32 persons who would be denied, totalling

$2.5 million, with a 1993 present value of $1.7 million.

The projected benefits of this provision were based on the review

of the related NTSB accident records. For second-class (commercial

pilots), only one general aviation accident was found where

hypertension or stroke was specifically listed as the cause. That

accident caused one death and destroyed one aircraft. Based on that

accident, commercial pilot accidents related to hypertension or stroke

are projected over the forecast period to equal: (1) .14 deaths per

year valued at $350,000 and (2) .14 destroyed airplanes per year valued

at $10,920, totalling $360,920 annually.

In addition to the directly attributable pathologies, high blood

pressure is also an associated risk factor for other pathologies

including cardiovascular disease and kidney failure. The exact impact

of the proposed rule on preventing accidents from these related

diseases is not known but the FAA estimates that the magnitude of

associated-disease accident costs that would be averted by the proposed

amendment is at least equal to 5 percent of the projected costs

attributable to second-class cardiovascular accidents. Such potential

benefits would total $342,964 per year. The combined (direct and

associated risk disease) potential benefits of the proposed second-

class blood pressure amendment over the ten-year study period are

expected to total $7.0 million, with a 1993 present value of $4.9

million. The FAA holds that the proposed amendment would meet or exceed

the 35 percent effectiveness level ($1.7 million cost / $4.9 million

potential benefit) necessary to be cost beneficial.

Blood Pressure, Third-Class

The proposal would add a new requirement that the sitting blood

pressure of all applicants for third-class medical certificates not

exceed 150/95 millimeters of mercury. The projected ten-year costs of

the provision are $2.8 million in primary testing costs and $1.0

million of additional testing and processing costs for those persons

who would not meet the standard, including 48 persons who would be

denied, totalling $3.8 million, with 1993 present value of $2.7

million.

The projected benefits of this provision were based on a review of

the related NTSB accident records

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